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

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on February 24, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient office visit (99214) provided on 
February 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office outpatient visit (99213) provided on October 24, 2019 with 
an out-of-network provider. 
 
You asked the Plan to pay for the office visit. You say that the services were referred by a contract provider. 
The Plan denied your request. The Plan says that prior authorization must be obtained to receive services 
provided by an out-of-network provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for an office visit by a contract provider. The file does not show that the plan 
provided notice that an office visit would not be covered. Under Medicare rules, this means the office visit is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the office outpatient visit 
(99213) provided on October 24, 2019 with an out-of-network provider.  
 
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 the annual wellness visit provided on May 7, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that when you enrolled with this insurance 
plan, you were assured that your coverage would be the same, and your two doctors were in network. The Plan 
denied your request. The Plan says the service was rendered by a non-contracted provider. The Plan also says 
that the services were 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 
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 annual wellness visit provided on May 7, 2020 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray exam of the abdomen (74018) 
provided on May 29, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
service provided. 
 
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 per day, per provider, for Medicare-covered x-ray services.  
 
You have been asked to pay a $35 copayment for the Medicare-covered x-ray service provided. 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 x-ray exam of the abdomen (74018) provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment charged for urgent care provided on May 
1, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe you owe this copayment. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 enrollees must pay $45 
copayment for urgent care services. You have been asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the $45 copayment charged for urgent care provided on May 1, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan Eye Drops. 
 
You asked the Plan to pre-approve the eye drops. You say that you would like reconsideration because the eye 
drops are medically necessary. The Plan denied your request. The Plan says this drug is not covered for the 
member's condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan Eye Drops.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit (99215) provided on April 1, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that medically necessary services were rendered in good faith.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only incases 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 forthe outpatient office visit (99215) provided on April 1, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medics determined after two EKG's you 
should go to the emergency room without their transport. 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 3, 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 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on January 3, 2020, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 psychotherapy (90837) provided on January 3, 
2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the psychiatrist services provided from May 30, 
2019, to December 18, 2019. 
 
You asked the Plan to reimburse you for the psychiatrist services. You say that it is impossible to find a 
psychiatrist who would except Medicare payments. The Plan denied your request. The Plan says this provider 
opted out of Medicare on July 5, 2018, therefore reimbursement is denied correctly. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to 
reimburse you for the services provided from May 30, 2019, to December 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
out-of-network care may only be approved if the member has a medical problem that needs urgent or emergent 
attention or has special needs for a medical problem such that a network provider cannot provide the needed 
service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physical therapy services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not have need for daily skilled nursing or therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  
 
Benefits for Ozempic 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a diagnostic test provided by a 
participating provider on July 21, 2020. 
 
You asked the Plan to waive the coinsurance for a diagnostic test. You say that you never went to the hospital. 
The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 10% 
coinsurance for outpatient diagnostic tests/in-network/diagnostic tests.  
 
You have been asked to pay a 10% coinsurance of the allowed amount for a diagnostic test. The total allowed 
amount is $55.20. The total amount you are being asked to pay is $5.52 ($55.20 x 10% = $5.52). The test that 
was provided was analyzed by an outpatient hospital facility; therefore, the correct coinsurance has been 
applied. A diagnostic test falls within the outpatient diagnostic tests/in-network/diagnostic tests 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 a diagnostic test provided by a participating 
provider on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on January 7, 2020, to February 19, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that a $40 copayment was already 
paid. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $40 copayment for physician/practitioner services/specialist.  
 
The enrollee has been asked to pay a $40 copayment for each specialist services. The total amount you are 
being asked to pay is $120 ($40 x 3 visits = $120). Specialist services falls within the physician/practitioner 
services/specialist 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 
specialist services provided by a participating provider on January 7, 2020, to February 19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has Covid-19. The enrollee 
received oral medications and insulin. The enrollee had stable vital signs. The enrollee did not receive nor 
require any skilled therapy. The documentation does not support that the enrollee requires the specialized skills, 
knowledge, or judgment of a skilled qualified therapist to safely and effectively provide medically necessary 
and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services 
are required on a daily basis.  

As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on April 6, 
2020. 
 
You asked the Plan to pay for the testing services. You say that the test was ordered to inform treatment 
decisions. The Plan denied your request. The Plan says current literature does not support the test as standard of 
care for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. Based on the information provided, we decided that Medicare rules 
for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
DecisionDx-Melanoma testing provided on April 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 20, 2018, to 
November 22, 2018. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the treating physician exercised their 
expert opinion in electing to admit this enrollee out of concern for an escalating clinical condition. The Plan 
denied your request. The Plan says that inpatient services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. The inpatient admission was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 20, 2018, to November 22, 2018.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 8, 
2020. 
 
You asked the Plan to pay for dental code D4910. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D4910 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910) provided on January 8, 2020.