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

 
We decided that the Plan does not have to pay for the physician services provided on December 15, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the physician services. You say that you have provided medical records so the 
claim can be processed 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. 
  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 physician services provided on December 15, 
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 July 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. 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 an office visit provided on July 15, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echo and specialist services provided 
from January 25, 2022, to January 28, 2022. 
 
You asked the Plan to waive the copayment for an echo and specialist services. You say that you are being 
charged two copays for one test. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay, when 
in-network, a $20 copayment for services performed by a provider other than your primary care physician. 
Your contract with the Plan also clearly says that you must pay, when in-network, a $35 copayment for 
physician specialist services. 
 
You have been asked to pay a total of $55 for the echo and specialist services. An echo falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. Specialist services fall 
within 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 copayment for the echocardiography (echo) and specialist services provided from 
January 25, 2022, to January 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has psoriasis. He has not 
tried and failed the Plan's required drug, a traditional systemic agent (methotrexate [MTX], cyclosporine, 
acitretin tablets, or psoralen plus ultraviolet A light [PUVA]). The records do not show that the required drug 
would be contraindicated or less effective; therefore, Ilumya is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new 
patient (99342) rendered by the out-of-network (OON) provider on August 5, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the home visit for the evaluation and management of a new patient (99342) rendered 
by the out-of-network (OON) provider on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 20, 2021 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 the services were provided out-of-network and 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 the office visit provided on December 20, 2021 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy (code 19083) provided on 
January 31, 2021. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that this was not technically an 
outpatient surgery but only a biopsy. You also say that only fluid was removed. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery at an outpatient surgery.  
 
The record shows a breast biopsy (code 19083) is considered a surgical procedure. You have been asked to pay 
a $350 copayment for a breast biopsy. A breast biopsy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a breast biopsy (code 19083) provided on January 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits (99214 x 2) provided on 
May 24, 2021 and November 17, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services 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 $40 
copayment for each in-person specialist visit.  
 
You have been asked to pay $80 ($40 copay x 2) for the in-person specialist office visits 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 copayments for the office visits (99214 x 2) provided on  
May 24, 2021 and November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of a spinal nerve provided on February 15, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the spinal nerve destruction. You say that authorization was obtained, and the 
service was medically necessary. The Plan denied your request. The Plan says the provider is out-of-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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the destruction of a spinal nerve provided on February 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a special push wheelchair. 
 
You asked the Plan to pre-approve a special push wheelchair. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered when specific criteria 
are met. 
 
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 a special push wheelchair. Our reviewer 
says that the services are medically necessary. Our physician reviewer found per clinical documentation, the 
enrollee has non-functional limits to mobility with a walker (not able to ambulate a household distance) without a transport chair and bracing. The enrollee has manual dexterity/strength to operate an ultra lightweight 
manual wheelchair per wheelchair clinic documentation and the enrollee requires an ultra light weight manual 
wheelchair for increased independence and safety in home. The home is manual wheelchair compatible. Thus, 
a special push ultra light weight manual wheelchair is medically reasonable and 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 a special push wheelchair have been met. Therefore, we decided that the Plan 
has to pre-approve a special push wheelchair.  
 
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 office visit provided on September 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you did not know you did not have coverage out-of-
state. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. The records provided for review do not show that the service at issue was urgent or emergent. 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 office visit provided on September 14, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on January 12, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you only went to get a COVID-
19 test and that it should be covered. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for diagnostic procedures and tests when given at a specialist office.  
 
You have been asked to pay $40 for the specialist office visit. This is where you had your COVID test done. 
The specialist visit 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 the specialist visit provided on January 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the cataract surgeries (66999 x 2) rendered 
by the out-of-network (OON) providers on November 4, 2021 and November 5, 2021. 
 
You asked the Plan to issue reimbursement. 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 were rendered by out of network 
providers, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to issue reimbursement care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The providers in this case are not network providers with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the cataract surgeries (66999 x 2) rendered by 
the out-of-network (OON) providers on November 4, 2021 and November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
December 30, 2021. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you were not using the 
equipment and were trying to return it. The Plan denied your request. The Plan says the correct coinsurance 
was 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 20% 
coinsurance for equipment and supplies, including oxygen equipment. 
 
Item Allowed Amount 20% Coinsurance 
Portable Oxygen Machine $19.83 $3.97 
Oxygen Concentrator $103.26 $20.65 
Total:  $24.62 You have been asked to pay $24.62, which is 20% of the allowed amount for the oxygen equipment. The 
oxygen equipment 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 portable oxygen equipment provided on December 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for triamcinolone injections provided on 
October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the knee injections. You say that the office staff said the 
injections would be paid by your insurance company. You also say you do not recall having to pay for other 
knee injections by another provider. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$115.20, which is 20% coinsurance of the allowed amount for each knee injection ($576 allowed amount x 
20% coinsurance = $115.20). You have been asked to pay the total of $230.40 ($115.20 coinsurance x 2 
injections = $230.40).  The knee injections fall 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 triamcinolone injections provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for subcutaneous tissue debridement (code 
11042) provided on December 23, 2021. 
 
You asked the Plan to reduce the copayment for the tissue debridement. You say that you saw a medical 
specialist and should only have to pay a $40 copayment. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for outpatient surgery at an outpatient hospital.  
 
The record shows that subcutaneous tissue debridement (code 11042) is considered a surgical procedure. You 
have been asked to pay a $400 copayment for the tissue debridement. The tissue debridement falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 reduce the copayment for subcutaneous tissue 
debridement (code 11042) provided on December 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance response and treatment, no 
transport (A0998) provided on September 13, 2021. 
 
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 has been 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 $200 for 
each non-Medicare covered ambulance stabilization when there is no transport.    
 
You have been asked to pay $200 for the ambulance stabilization as no transport was 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 ambulance response and treatment, no 
transport (A0998) provided on September 13, 2021.