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

 
We decided that the Plan does not have to pay for abdominal paracentesis provided on November 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for abdominal paracentesis. You say that due to a clerical error, a referral 
authorization was not obtained by the primary care physician prior to services being rendered. You also say 
that it is your stance that the services were provided in good faith and were medically necessary. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for abdominal paracentesis provided on November 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve the continued inpatient mental health services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria is no longer met. 
 
The Plan follows Medicare rules. Medicare rules say that patients in inpatient psychiatric care may be 
discharged by stepping down to a less intensive level of outpatient care. Stepping down to a less intensive level 
of service than inpatient hospitalization would be considered when patients no longer require 24 hour 
observation for safety, diagnostic evaluation, or treatment. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued inpatient mental health 
services. Our reviewer says that continued inpatient services after May 12 are not medically necessary. Our 
physician reviewer found this patient does not meet the criteria for continued treatment in an acute inpatient 
mental health facily. The enrollee can be treated in a lesser restrictive setting as he was not showing any 
suicidal or homicidal ideation, auditory or visual hallucinations, and was not showing any aggressive behaviors 
while being cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued inpatient mental health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you were under the 
impression there would only be a $25 copayment. 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 $95 
copayment for in-network diagnostic procedures and tests at an outpatient hospital. 
 
You have been asked to pay $95 for outpatient hospital services. Outpatient hospital services 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 outpatient hospital services provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement procedures performed 
from November 11, 2021, to January 27, 2022. 
 
You asked the Plan to waive the copayments for the wound debridement. You say that you thought these 
services would be $0 since they were done in a specialist's office 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 $325 
copayment for each outpatient hospital facility visit.  
 
You have been asked to pay $173.94 for the wound care provided on November 11, 2021, which is less than the $325 copayment. You have also been asked to pay a $325 copayment for each of the other 5 wound care 
visits. The total for all visits is $1,798.94. The wound debridement 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 copayments for wound debridement procedures performed 
from November 11, 2021, to January 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency services and pay for the 
drugs you were provided from December 11, 2020, to December 16, 2020. 
 
You asked the Plan to waive the copayment and pay for the drugs. The Plan denied your request. The Plan says 
you are responsible for the charges. 
 
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 $65 
copayment for emergency care. The rules also say that Medicare Part B generally does not pay for self-
administered drugs. 
 
Review of the file shows that you were provided emergency care and self-administered drugs from December 
11, 2020, to December 16, 2020. You have been asked to pay a $65 copayment for the emergency services. 
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. Additionally, you have 
been asked to pay the full cost of the self-administered drugs. The self-administered drugs requested here are 
not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have 
to waive the copayment for the emergency services and to pay for the drugs you were provided from December 
11, 2020, to December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on January 21, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request retroactive authorization. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were 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 Drug Testing provided on January 21, 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 specialist office visit and the application of multi-layer 
compression system provided on September 17, 2021, to September 29, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a specialist office visit and the application of multi-layer compression system. 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says there are 
no records of a prior authorization being obtained from the member's primary care physician (PCP) prior to the 
services being rendered from September 17, 2021, through September 29, 2021. 
 
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 specialist office visit and the application of 
multi-layer compression system provided on September 17, 2021, to September 29, 2021, 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 provided on September 
13, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be responsible 
for these services since you contracted MRSA during your hospital stay after you broke your hip. 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 $250 
copayment for ground ambulance services.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$250 copayment for ambulance services. Ambulance services fall 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 provided on September 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services provided on January 7, 
2022. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that are appealing the cost share 
applied. The Plan denied your request. The Plan says you have been charged the correct cost share 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 50% of 
the total cost for Medicare-covered, out-of-network outpatient lab services.  
 
 
 
 You have been asked to pay a total of $324.78 for the laboratory services.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 7, 2022 Laboratory Services $323.75 50% $161.88 
January 7, 2022 Laboratory Services $325.80 50% $162.90 
TOTAL    $324.78 
 
The laboratory 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 coinsurance for laboratory services provided on 
January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on April 14, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 April 14, 2021 by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional Ultramist ultrasonic treatments (of 18 
requested). 
 
You asked the Plan to pre-approve the 6 additional ultrasonic treatments. You say that the requested treatment 
plan should be approved in full. The Plan denied your request. The Plan says it was decided that 12 sessions 
can be approved at this time, with the need for further sessions being assessed after the first 12 are completed 
 
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 the 6 additional ultrasonic treatments. 
Our reviewer says that the requested number of sessions is not considered medically reasonable and necessary 
in this case. Our physician reviewer found the patient is a 71 year old male who has a stage IV pressure ulcer 
right hallux with reported benefit from using Medihoney. Eighteen Ultramist ultrasound treatments were 
requested. The Plan approved 12 total treatments only with the option of requesting additional session with 
evidence of benefit at the conclusion of these approved 12 sessions. This is reasonable, and there was no 
exceptional circumstances that would support 18 sessions rather than 12 sessions to start. Therefore, without 
sufficient support made for this request, the remaining 6 sessions of Ultramist ultrasound treatments will be 
considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 6 additional ultrasonic treatments have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional Ultramist ultrasonic treatments (of 18 requested).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and resin-based 
composite - two surfaces, anterior (D2331) provided September 8, 2021. 
 You asked the Plan to pay for the crown and resin-based composite. You say that these services were 
necessary, and you feel they should be covered. The Plan denied your request. The Plan says these services are 
not covered because the provider has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown and 
resin-based composite when you see any licensed provider who accepts Medicare patients in the United States 
and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the crown and resin-based composite have not been met. 
Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and resin-
based composite - two surfaces, anterior (D2331) provided September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter (E1399) purchased December 13, 2021. 
 
You asked the Plan to pay for the power scooter. You say that the electric scooter was prescribed by your 
provider because you cannot walk for very long. You struggle to walk and occasionally fall. The Plan denied 
your request. The Plan says the records provided does not support that the enrollee meets the criteria for 
reimbursement for the power scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 pay for the power scooter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical documentation to support medical need for a power scooter. Documentation 
states that patient ambulates and does not attest to other assistive device options or mobility impairment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power scooter have not been met. Therefore, we decided that the Plan does 
not have to pay for the power scooter (E1399) purchased December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on January 3, 2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you believe your copayment should 
be $0. 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 $35 
copayment for in-network Level 1 physician services to diagnose and treat diseases and conditions of the eye.  
 
 
 
 
 
 
 
 You have been asked to pay $35 for an eye exam. An eye exam falls within the Vision 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 the eye exam provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81240, 81241, 
81232, 81350, 81306, 81283, 81220, 81227, 81231, 81247, 81291, 81328, 81335, 81381) provided on June 28, 
2021. 
 
You asked the Plan to pay for a pharmacogenetic panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says the purpose of this testing is not documented.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that in order to be covered, laboratory services must be 
related to a patients illness or injury (or symptom or complaint). 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a pharmacogenetic panel (81225, 
81226, 81240, 81241, 81232, 81350, 81306, 81283, 81220, 81227, 81231, 81247, 81291, 81328, 81335, 
81381) provided on June 28, 2021. have been met. There is no documentation that this testing was related to 
the patients illness or injury. The records do not indicate why this testing was ordered or how it would affect 
the patients treatment. Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel 
(81225, 81226, 81240, 81241, 81232, 81350, 81306, 81283, 81220, 81227, 81231, 81247, 81291, 81328, 
81335, 81381) provided on June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery facility visit 
provided on September 16, 2021. 
 
You asked the Plan to waive the copayment for an outpatient surgery facility visit. You say that your insurance 
is supposed to cover all services. 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 $295 
copayment for in-network Medicare-covered surgery or other services provided to you at an ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have only been asked to pay the allowed amount of  $259.31 instead of the standard $295 copayment for 
the outpatient surgery facility visit. Outpatient surgery facility visits fall within the 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 outpatient surgery facility visit provided on September 16, 2021.