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

 
We decided that the Plan does not have to pay for lab work provided on June 1, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that this should be covered and was medically necessary. The 
Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 lab work provided on June 1, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monaural, behind the ear hearing aid (V5060) provided on 
April 12, 2022. 
 
You asked the Plan to pay for a monaural, behind the ear hearing aid (V5060). You say that you had a service 
done with this provider and were advised that the service provided would help you better than the hearing aids 
that were offered. The Plan denied your request. The Plan says the hearing aid was purchased through a non-
participating Plan hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by a Plan network provider.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say you must use an in-network Plan provider for this 
benefit. The record shows that this service was provided out-of-network with the Plan. Based on this 
information, we decided that the Plan's rules for coverage of a monaural, behind the ear hearing aid (V5060) 
have not been met. Therefore, we decided that the Plan does not have to pay for a monaural, behind the ear 
hearing aid (V5060) provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the facility does not see patient's and cannot 
facilitate authorization. The Plan denied your request. The Plan says a referral/authorization was not obtained 
prior to services being rendered. 
 
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 laboratory services provided on July 5, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on June 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 principal care management services provided on 
June 8, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy sessions provided in a skilled nursing facility 
provided from May 12, 2022, to May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy sessions provided in a skilled nursing facility. You say that the enrollee 
is in a facility and the facility should have obtained the prior authorization.  
 The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
 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 therapy sessions provided in a skilled nursing 
facility provided from May 12, 2022, to May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an establishing visit with labs provided on May 10, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an establishing visit with labs. You say that this should be covered. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. There are 
other providers within your network. Therefore, the decision is upheld. 
 
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 establishing visit with labs provided on May 
10, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on June 9, 
2022, to June 24, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you are disputing the 
share cost. 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 $188 per 
day for skilled nursing facility care. This skilled nursing facility (SNF) care lasted 15 days, resulting in 
deductible amount of $2,408.35 instead $2,820 due to out of pocket max being met for the 2022 plan year. 
 
You have been asked to pay $188 per day for skilled nursing facility. This item/service falls within the skilled 
nursing facility 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 skilled nursing 
facility provided on June 9, 2022, to June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of a refractive state (92015) provided on 
August 25, 2022. 
 
  You asked the Plan to pay for a determination of a refractive state (92015). You say that you were referred to 
this provider by your primary care physician due to a possible need for cataract surgery. You also say your visit 
was strictly medical and you were not looking for any routine eyecare service. The Plan denied your request. 
The Plan says covered vision care includes eye refraction to determine changes in your vision and or the need 
for eyeglasses or contact lenses when provided by a Plan participating provider for a routine vision 
care. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when eye refractions during a routine examination when performed by 
a Plan routine vision care provider. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover eye refractions during a routine 
examination when performed by a Plan routine vision care provider. Based on this information, we decided that 
the Plan's rules for coverage of a determination of a refractive state (92015) have not been met. Therefore, we 
decided that the Plan does not have to pay for a determination of a refractive state (92015) provided on August 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on June 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that it was medically necessary to treat 
the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 outpatient hospital services provided on June 
30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for pain management provided on April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit for pain management. You say that you needed this visit for pain 
management. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 for pain management provided on 
April 11, 2022, 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 acupuncture treatment (97810, 97811) provided on 
November 16, 2021. 
 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 at issue are not payable as they 
were rendered by an ineligible provider type. 
 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were rendered 
by a licensed acupuncturist who was not under the supervision of a physician, physicians assistant, nurse 
practitioner, or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
July 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date of service July 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 self-test (K1034) provided on May 23, 2022 to 
May 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the COVID-19 self test. You say that the items should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the items denied correctly as they were 
provided by a non-participating provider and could have been provided in-network. 
 
 
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 COVID-19 self-test (K1034) provided on May 23, 
2022 to May 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 19, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says authorization was not obtained prior to services being 
rendered. 
 
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 domiciliary or rest home visit provided on July 
19, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99349), urinalysis (81002), and insertion of 
temporary indwelling bladder catheter (51702) provided on June 19, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the home visit, urinalysis, and insertion of temporary indwelling bladder 
catheter. The Plan denied your request. The Plan says these services were rendered by an OON provider, and 
are not covered by Original Medicare or by the Plan. 
 
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 home visit (99349), urinalysis (81002), and 
insertion of temporary indwelling bladder catheter (51702) provided on June 19, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for debridement provided on March 8, 2022. 
 
You asked the Plan to waive the coinsurance for Debridement. You say that you are disputing the share cost. 
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 50% 
coinsurance after $100 deductible for Class 2 Basic Services. You must pay $100 deductible. The allowed 
amount of debridement procedure total $25.39, resulting in a coinsurance amount of $12.70. Therefore the total 
cost is $112.70 ($100 + $12.70 = $112.70). 
 
You have been asked to pay 50% coinsurance after $100 deductible for debridement. This item/service falls 
within the Class 2 Basic 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 coinsurance for 
debridement provided on March 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fecal occult blood test provided on July 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the fecal occult blood test. You say that the test should be covered you followed 
the instructions and mailed it in. The Plan denied your request. The Plan says the rendering provider is an OON 
provider, and the claim was processed correctly. 
 
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 fecal occult blood test provided on July 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the plan has a Point-of-Service (POS) benefits which provides coverage for certain 
out-of-network services as long as the services are covered benefits and are medically necessary. If you use an 
out-of-network provider, the enrollee must follow the same medical necessity requirements that apply for in-
network provider. The enrollee may request a Prior Authorization from the plan before accessing services. See 
Chapter 4 for covered services and prior authorization requirements.  
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 lab testing provided on April 11, 2022, by an out-
of-network (OON) provider.