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

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on June 29, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you don't understand why 
you are being asked to pay 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 $20 
copayment for Physician/Practitioner services/specialist visit.  
 
You have been asked to pay a $20 copayment for specialist office visit. This item/service falls within the 
Physician/Practitioner services/specialist visit 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 specialist office visit provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a Part B drug, x-rays, and office visits 
provided from March 2, 2022 to July 7, 2022. 
 
You asked the Plan to waive the cost share for the Part B drug, x-rays, and office visits. You say that you 
would like to appeal the copayments you are being charged for the x-rays, follow-up care and would like the 
charges lessened. 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 15% 
coinsurance for Medicare Part B prescription drugs, a $20 copayment for each basic imaging service, and $30 
copayment for each in-person specialist visit.  
You have been asked to pay a 15% coinsurance for the Part B drug, and copayments for the x-rays, and office 
visits.  
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
 
COPAYMENT 
 
COINSURANCE 
March 2, 2022 73552 $34.46 $20.00  
March 24, 2022 73552 $34.46 $20.00  
April 14, 2022 73552 $34.46 $20.00  
May 5, 2022 73552 $34.46 $20.00  
May 5, 2022 J3301 $8.96 - $1.34 
May 24, 2022 73552 $34.46 $20.00  
May 24, 2022 99213 $89.01 $30.00  
June 16, 2022 73552 $34.46 $20.00  
June 16, 2022 99213 $89.01 $30.00  
July 7, 2022 73552 $34.46 $20.00  
July 7, 2022 99213 $89.01 $30.00  
TOTAL    $231.34 
 
The Medicare Part B prescription drug falls under the Medicare Part B prescription drugs benefit category. The 
x-rays fall under the outpatient diagnostic tests and therapeutic services and supplies benefit category. The 
office visits fall under 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. Therefore, we decided that 
the Plan does not have to waive the cost share for a Part B drug, x-rays, and office visits provided from March 
2, 2022 to July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 8, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the services rendered on this claim are for 
continuity of care for a serious chronic condition previously treated in our facility. The Plan denied your 
request. The Plan says the out-of-network services were 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 an office visit provided on June 8, 2022, by an 
OON provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the repeat radiofrequency ablation (RFA) (64636, 64635). 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 the RFA. Our reviewer says that the 
procedure is medically necessary and reasonable. Our physician reviewer found the enrollee's last round of 
RFA produced 80% pain relief for almost a year. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the RFA have been met. Therefore, we decided that the Plan has to pre-approve 
the repeat radiofrequency ablation (RFA) (64636, 64635).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on July 18, 2022, 
to August 3, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per admission, no more than $900 in a calendar year for inpatient hospital services.  
 
You have been asked to pay a $300 copayment per admission, no more than $900 in a calendar year for 
inpatient hospital services. 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 copayment for inpatient hospital services on July 18, 2022, to August 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test purchased on 
August 14, 2022. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you needed this test kit because you were 
exposed to a person who had COVID-19. The Plan denied your request. The Plan says this request for 
reimbursement has been correctly denied. The Plan also says that the OTC COVID-19 test is not a covered 
benefit with the Plan, but is a covered benefit with Original Medicare. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 test is an OTC item. The Plan does not offer a supplemental benefit covering this service, as this is 
not currently required by Medicare. However, for future purchases, these can be obtained with participating 
providers and covered by Original Medicare when using your Medicare card rather than your Plan card. 
Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, we 
decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test purchased on August 
14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a plethysmography for determination of lung volumes, a 
carbon monoxide diffusing capacity, and a breathing capacity test provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a plethysmography for determination of lung volumes, a carbon monoxide 
diffusing capacity, and a breathing capacity test. You say that you have attached medical records supporting the 
medical necessity for services provided to the member. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan. The Plan also says that the services were not referred by a 
network provider or rendered in a participating facility. The Plan also says that the services were not 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 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 a plethysmography for determination of lung 
volumes, a carbon monoxide diffusing capacity, and a breathing capacity test provided on May 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (codes 81432 and 81433) provided on 
June 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the testing will guide the enrollee's medical 
management. The Plan denied your request. The Plan says the testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the genetic testing have been met. 
Specifically, there are no medical records from the ordering provider. Therefore, we decided that the Plan does 
not have to pay for the genetic testing (codes 81432 and 81433) provided on June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on April 15, 2021, to 
April 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a 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 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 an inpatient hospital stay provided on April 15, 
2021, to April 20, 2021, 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 chemo denervation of trunk muscles and an 
onabotulinumtoxina injection provided on July 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chemo denervation of trunk muscles and an onabotulinumtoxina injection. 
You say that you are resubmitting the claim with supporting documentation to support these services. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
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 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 chemo denervation of trunk muscles and an 
onabotulinumtoxina injection provided on July 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gene expression profiling provided on March 22, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the gene expression profiling. The Plan denied your request. The Plan says the 
out-of-network services were 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 gene expression profiling provided on March 22, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee must receive care from a 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 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 an office visit provided on August 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary that the enrollee receive 
SNF care. The Plan denied your request. The Plan says the Medicare criteria for SNF admission were not met 
and the enrollee can receive the care that they need at an alternate lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
SNF setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services were authorized. The Plan denied your 
request. The Plan says the enrollee must receive are from a 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 had network providers 
available who could have provided the item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on March 8, 2022, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on April 16, 2022, by OON 
provider. 
 
You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says the out-of-
network services were 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 ambulance transport provided on April 16, 2022, 
by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. The Plan denied your request. The 
Plan says you have used all 12 allotted trips for the benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require intensive acute therapy to address a chronic fixed spinal 
stenosis. The enrollee does not require frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the pelvic exam (99397), provided on July 11, 2022. 
 
You asked the Plan to pay for the pelvic exam. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that you have exhausted the plan benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. because the Plan has not provided any documentation showing when the enrollee 
last received a covered pelvic exam. Therefore, we decided that the Plan has to pay for the pelvic exam 
(99397), provided on July 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.