Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on June 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that the services were medically necessary. 
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 mental health services provided on June 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic test on June 23, 2022. 
 
You asked the Plan to waive the copayment for diagnostic test. You say that you want to appeal the amount 
being charged. 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 $75 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service. Covered 
services include other outpatient diagnostic tests including advanced imaging services. The provider billed in 
the amount of $108 and the allowed amount is $41.20. This is less than the copayment amount. Therefore, 
results in the total cost sharing amount of $41.20. 
 
 
 
 
 You have been asked to pay a $41.20 copayment, which is less than the copayment for diagnostic test. This 
item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for diagnostic test on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walking boot provided on May 11, 2022. 
 
You asked the Plan to waive the coinsurance for a walking boot. You say that urgent care gave you the wrong 
size boot and would not take it back due to covid. You feel you should not owe this coinsurance. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this service or 
item is $325.53, resulting in a coinsurance of $65.11 ($325.53 x 20% = $65.11). 
 
You have been asked to pay a $65.11 coinsurance for a walking boot. This item/service falls within the durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a walking boot provided on May 11, 2022.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve autosomal dominant tubulointerstitial kidney disease-UMOD 
(ADTKD-UMOD) genetic testing. 
 
You asked the Plan to pre-approve ADTKD-UMOD genetic testing. You say that the requested genetic testing 
is medically necessary. The Plan denied your request. The Plan says that the requested genetic testing is not 
medically necessary. 
 
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. Specifically, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the requested genetic testing. The Plan stated 
that they made their decision based on medical records received; however, these were not provided after we 
made attempts to obtain them. Therefore, we decided that the Plan has to pre-approve autosomal dominant 
tubulointerstitial kidney disease-UMOD (ADTKD-UMOD) genetic testing.  
 
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 initial hospital care (99222) provided on June 12, 2022. 
 
You asked the Plan to pay for procedure code 99222. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99222 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the records provided note 
that initial hospital care coded as 99223 with a date of service of June 9, 2022, was previously paid by the Plan. 
These services were performed by a different provider as the June 12th claim. It does not appear appropriate for 
the Plan to pay a second time for services billed as initial inpatient hospital care. There is a more appropriate 
code that would reflect the services performed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan does not have to pay 
for the initial hospital care (99222) provided on June 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need to be transported to the 
hospital. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 May 24, 2022. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provide on 
May 23, 2022, and June 20, 2022. 
 
You asked the Plan to waive the copayment for doctor's office visit. You say that you should not be liable for 
an office copay. 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 $35 
copayment for each specialist office visit. There were 2 visits, resulting in a total copayment amount of $70. 
 
You have been asked to pay $43.74, which is less than $70 copayment for two doctor's office visits. This 
item/service falls within each visit for a specialist office 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 physician/practitioner service provide on May 23, 2022, and June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provided on 
December 16, 2022. 
 
You asked the Plan to waive the copayment for doctor's office visit. You say that you should not be liable for 
the $45 copayment because the provider only spoke to him and did not carry out any tests or other services. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for services obtained from a specialist.  
 
You have been asked to pay $45 copayment for doctor's office visit. This item/service falls within the services 
obtained from a specialist 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 
physician/practitioner service provided on December 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound scan of axillary lymph nodes 
provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound scan. You say that you do not understand why 
this ultrasound of his axillary lymph nodes was not paid. 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 $150 
copayment for Medicare covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $150 copayment for ultrasound scan. This item/service falls within the Medicare 
covered radiological diagnostic services, not including X-rays, performed in a physicians office or at a free-standing facility (such as a radiology center or medical clinic) benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an ultrasound scan of axillary lymph nodes provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting a reconsideration of the 
denial for payment. You say that you would like the records reviewed and the claim paid. The Plan denied your 
request. The Plan says an authorization was not obtained prior to the laboratory services being performed. 
 
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 June 2, 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 injections on May 20, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for all other drugs covered under Medicare Part B. Covered drugs include drugs that arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. The provider billed in the amount of $7,159.24 and the allowed amount is 
$1,275.60. $1,275.60 x 20% = $255.12. Therefore, results in the total cost sharing amount of $255.12. 
 
You have been asked to pay a 20% coinsurance for injections. This item/service falls within the Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections on May 
20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 17, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under open access unless preauthorized. 
 
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 
services at issue. 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 June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not request the 
ambulance and would not have accepted if you knew the 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 a $260 
copayment for one-way ambulance services. 
 
You have been asked to pay a $260 copayment for the ambulance services. This item/service falls within the 
one-way ambulance 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 copayment for the 
ambulance services provided on June 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 03, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were told there would be 
no charge for this. 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 $325 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 outpatient surgery provided on March 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a home ventilator provided from July 1, 
2022, to August 1, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you are on a 
fixed income and cannot afford this coinsurance. 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 durable medical equipment (DME) and related supplies.  
 
You have been asked to pay 15% coinsurance of the allowed amount for durable medical equipment (DME). 
The total allowed amount for one month is $622.23. The amount you are being asked to pay per month is 
$93.33 ($622.23 x 15% = $93.33). The total amount you are being asked to pay is $186.66, which is less than 
your coinsurance amount of $186.66 ($93.33 x 2 months = $186.66). This item/service falls within the durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a home ventilator provided from July 1, 2022, to August 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must either have a history of osteoporosis-related fracture OR 
has tried and failed zoledronic acid. 
 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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the Plan requires either a history of 
osteoporosis-related fracture, OR a trial of zoledronic acid first before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating 
that the plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractor services provided on May 05, 2022, to June 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractor services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says as a member of our plan, the enrollee must use network providers. If the 
enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee 
will be responsible for the entire cost.   
 
 
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 chiropractor services provided on May 05, 2022, 
to June 16, 2022, by an out-of-network (OON) provider.