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

 
We decided that the Plan does not have to pay for physician's services provided on August 13, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required under the Plan benefits. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 24, 2020 by a non-
participating provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on July 24, 2020 by 
a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dental extractions provided on September 8, 2020.
You asked the Plan to waive the coinsurance for the dental extractions. You say that your spouse was told by the Plan that the extractions would be paid for by insurance. The Plan denied your request. The Plan says they reviewed the phone call and correct information of the 50% coinsurance was given.
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 Oral Surgery. You have been asked to pay 50% coinsurance for the dental extractions. The dental extractions fall within the Oral 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 coinsurance for the dental extractions provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on July 16, 2020.
You asked the Plan to waive the copayment for vision care. You say that you feel that you should owe a $15 copayment instead of a $40. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 each outpatient visit for services to diagnose and treat a disease or condition of the eye for vision care. The medical records show that you received vision care to diagnose and treat a disease or condition of the eye on July 16, 2020. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for vision care. Vision care falls within the vision 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 vision care provided on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab injection (J0897). 
 
You asked the Plan to pre-approve denosumab injection. You say that the service is medically necessary. The 
Plan denied your request. The Plan says Part D covers when the pharmacy dispenses the drug to you to self-
administer, or to take it to your provider; or is given in a long term care facility (LTC); or is given in your 
home or in assisted living- without an infusion pump. Part B covers in all other circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve denosumab injection (J0897).  
 
Benefits for denosumab injection may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G4 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G4 CGM. You say that the enrollee's current monitor is not 
working. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G4 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G4 continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and the fire department assisted 
you. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, while you are a member of our plan you must use network providers to get your medical 
care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is 
not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the 
Plan authorizes use of out-of-network providers. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography provided on June 22, 
2020. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that you were billed for two 
procedure but only should have been billed for one. You say that you should be reimbursed for this amount. 
The Plan denied your request. The Plan says the copayment applied 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 $45 
copayment for other Medicare-covered outpatient diagnostic tests from a specialty physician. 
  
You have been asked to pay a $45 copayment for the echocardiography. The echocardiography falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that two 
diagnostic tests were billed by two different providers, which apply separate copayments. 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 echocardiography provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
September 9, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided do not meet criteria for 
coverage under the member?s contractual policy. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
 
 
 
We looked at the file and the Plan?s rules. Based on this information, we decided that the Plan?s rules for 
coverage of the acupuncture services have not been met. Specifically, the acupuncture was not provided by a 
physician licensed to perform the service. This means that the acupuncture services are not eligible for 
coverage by the Plan. Additionally, these services were not provided for treatment of chronic lower back pain 
and are therefore, also not eligible for coverage by Medicare. Therefore, we decided that the Plan does not have 
to pay for the acupuncture treatment (97810, 97811) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 to 
November 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on November 19, 
2019 to November 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (J3301, J0702, 70220, 99213) provided on May 23, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent and there were network providers available.
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 has network providers available who can provide 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 physician services (J3301, J0702, 70220, 99213) provided on May 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 12, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that there is no network deficiency for these services. 
 
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 has network providers 
available who can provide 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 medical services provided to the enrollee on 
August 12, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from July 15, 2020, to July 29, 2020. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were not 
aware that you would owe a copayment. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 outpatient rehabilitation services.  
 
You received outpatient rehabilitations services from July 15, 2020, to July 29, 2020 for a total of 5 visits. 
Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $30 
(copayment) x 5 (outpatient rehabilitation services) = $150.  
 
You have been asked to pay the total copayment amount of $150 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from July 15, 2020, to 
July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on March 30, 2020, to April 9, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should be reimbursed based on the Medical Financial Assistance program. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 enrollee's contract with the Plan clearly says that enrollees must pay a $235 copayment per day for days 1-7, no charge for remainder of stay for inpatient hospital care. The enrollee has been asked to pay a $235 copayment per day for days 1-7, no charge for remainder of stay for the inpatient hospital care. the inpatient hospital care falls within the inpatient hospital care benefit category. 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 copayment for the inpatient hospital care provided on March 30, 2020, to April 9, 2020.
Your complaint about potentially not receiving information that your stay would not be covered under the Medical Financial Assistance program is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan 
denied your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that 
Synvisc-One is not medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires 
these be trialed first. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the Continuous Glucose 
Monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Continuous Glucose Monitor is covered when 
the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee uses insulin three or more 
times daily. Based on this information, we decided that Medicare rules for coverage of the continuous glucose 
monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (K0554).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the medical services provided.