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

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the office visit was for a follow-up, and you would 
like the Plan to pay for the service. 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 an office visit provided on May 17, 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 frames (V2020), spherocylinder, bifocal lenses (V2203) and 
vision supplies (V2797) provided on March 29, 2022. 
 
You asked the Plan to pay for frames (V2020), spherocylinder, bifocal lenses (V2203) and vision supplies 
(V2797). You say that you are 89 years old and live on a fixed income. The Plan denied your request. The Plan 
says the member went to a provider who is not in their network. 
 
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 they are provided by an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must use network providers to get 
medical care and services. The record shows these services were provided by an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of frames (V2020), spherocylinder, 
bifocal lenses (V2203) and vision supplies (V2797) have not been met. Therefore, we decided that the Plan 
does not have to pay for frames (V2020), spherocylinder, bifocal lenses (V2203) and vision supplies (V2797) 
provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that a referral is not required for the patient's plan. 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 29, 2022, 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 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you made the appointment with the provider before 
you ever received a card in the mail. 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 an office visit provided on July 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 laboratory services related to end-stage renal disease 
(ESRD) provided on June 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 9, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that the provider who ordered this test 
should pay this 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $21.05 which is less than the $320 copayment for a CT 
scan. 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 a computed tomography (CT) 
scan provided on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 7, 2021. 
 
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(s) of service December 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services (codes 97082 and 
97083) provided from April 16, 2021, to June 22, 2021. 
 
You asked the Plan to pay for the medical nutrition therapy services. You say that you did not know there was 
a time limit to send the claim in for reimbursement. The Plan denied your request. The Plan says this claim was 
untimely, and the submission did not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical nutrition therapy services was not filed until June 28, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services (codes 
97082 and 97083) provided from April 16, 2021, to June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the excision of a bone provided on March 
15, 2022. 
 
You asked the Plan to waive the copayment for the excision of a bone. You say that your provider said you 
were doubled billed for the same procedure. The Plan denied your request. The Plan says the Plan does not bill 
enrollees for procedures and the replacement claim was processed correct; therefore, 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 $120 
copayment for each Medicare-covered visit to an ambulatory surgical center.  
 
  You have been asked to pay a $120 copayment for the excision of a bone. This item/service falls within the 
outpatient surgery, including 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 waive the copayment for the excision of a bone provided 
on March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 12, 2022. 
 
You asked the Plan to waive the copayment for ambulance. 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 $200 
copayment per one-way trip. Covered ambulance services include fixed wing, rotary wing, and ground 
ambulance services to the nearest appropriate facility that can provide care if they are furnished to a member 
whose medical condition is such that other means of transportation could endanger the person's health or if 
authorized by our plan. 
 
You have been asked to pay a $200 copayment for ambulance. This item/service falls within the 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 ambulance on May 12, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transfer to a nursing home provided on May 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ambulance transfer to a nursing home. You say that this was done in good faith 
and should be covered. The patient needed this service. 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. This was a non-emergent ambulance service. 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 ambulance transfer to a nursing home provided on 
May 23, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure. 
 
You asked the Plan to pre-approve a VivAer procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a VivAer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee has chronic rhinitis in the setting of 
nasal obstruction. There is insufficient literature to support the safety and efficacy of the requested service for 
the enrollee's specific conditions compared to the accepted surgical standards of care. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VivAer procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on March 2, 
2022, to March 6, 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 $205 
copayment per day for inpatient hospital services. The total cost share is $820. 
 
You have been asked to pay a $205 copayment per day 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 March 2, 2022, to March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an electrocardiogram provided on August 
24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and an electrocardiogram. You say that you have appealed the 
claim. The Plan denied your request. The Plan says the rendering provider is a non-participating provider with 
the Plan. The Plan also says they did not authorize services for this 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 and an electrocardiogram provided 
on August 24, 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 an orthopedic visit with a radiological exam provided on 
February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an orthopedic visit with a radiological exam. You say that this provider did your 
surgery, and this should be covered. You believe this was a clerical error. 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 orthopedic visit with a radiological exam 
provided on February 17, 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 wound care provided on June 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 wound care provided on June 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services on June 19, 2022. 
 
You asked the Plan to waive the copayment for ambulance 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
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 ambulance services 
on June 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine studies of the heart 
muscle at rest and with stress using a single-photon emission computed tomography (SPECT) technique 
provided on May 31, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine imaging. You say that you were never 
admitted as an outpatient and the procedure was performed in an office facility. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. Services obtained in a hospital or clinic setting are 
considered outpatient when no hospital admission takes place.  
 
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 hospital services. 
 
You have been asked to pay a $325 copayment for nuclear medicine imaging. This item/service falls within the 
outpatient hospital 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 nuclear medicine studies of the heart muscle at 
rest and with stress using a single-photon emission computed tomography (SPECT) technique provided on 
May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on January 25, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you would like to be reimbursed 
for the test kits. The Plan denied your request. The Plan says COVID-19 test kits were not a covered benefit at 
the time you made this purchase. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits is an OTC item. However, the Plan offers a supplemental benefit for over-the-counter 
home COVID-19 tests purchased after February 1, 2022. These tests were purchased on January 25, 2022, 
which is before this benefit went into effect. Therefore, we decided that the Plan does not have to pay for the 
at-home COVID-19 test kits purchased on January 25, 2022.