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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan. You say that you need a CT scan. The Plan denied your request. 
The Plan says the services have been requested from an out-of-network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the extremity veins 
provided on November 10, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that it does not look like the insurance 
company covered any part of this service. 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 $160 
copayment for in-network radiological diagnostic services, including ultrasounds at a free-standing facility.  
 
 The ultrasound is a covered service that has cost sharing. If the allowed amount is less than the cost sharing 
amount found in the EOC, you are responsible for the full allowed amount. The record shows Medicare 
approved the allowed amount of $120.65 for the ultrasound. You have been asked to pay the allowed amount 
of $120.65, which is less than the $160 copayment for an ultrasound. An ultrasound 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 an ultrasound of the extremity veins provided on November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography with contrast, or without 
contrast followed by with contrast, real-time with image documentation (C8929) and a sulfur hexafluoride lipid 
microspheres injection (Q9950) provided on October 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a transthoracic echocardiography with contrast, or without contrast followed by 
with contrast, real-time with image documentation and a sulfur hexafluoride lipid microspheres injection. You 
say that this provider provides care at the direction of the attending physician, and in turn, requests 
reimbursement for services rendered to the member.  The Plan denied your request. The Plan says after review, it was determined that there are no records of a 
referral from the member's primary care physician to the Plan prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a transthoracic echocardiography with contrast, or 
without contrast followed by with contrast, real-time with image documentation (C8929) and a sulfur 
hexafluoride lipid microspheres injection (Q9950) provided on October 22, 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 subsequent nursing facility care provided on  
September 6, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you cannot walk going up the steps, your knee 
buckles and you lose balance and sometimes fall. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) scan of the 
abdomen and pelvis and contrast agent provided on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for the CT scan and contrast agent. You say that you thought the 
provider was in-network. You say that you were expecting a 20% coinsurance. 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 40% 
coinsurance for advanced imaging services provided at an out-of-network (OON) specialist's office. 
 
Your contract with the Plan also clearly says that you must pay a 40% coinsurance for medical supplies from 
an out-of-network (OON) provider, including contrast agents. 
 
Service/Item Allowed Amount 40% Coinsurance 
CT Scan $237.20 $94.88 
Contrast Agent $7.20 $2.88 
Total:  $97.76 
 
You have been asked to pay $97.76, which is 40% of the allowed amount for the CT scan and contrast agent. 
The CT scan and contrast agent fall 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 a computed tomography 
(CT) scan of the abdomen and pelvis and contrast agent provided on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on October 22, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the drug test. You say that you disagree with the denial. 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 drug test provided on October 22, 2021, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pulmonary specialist office visit provided 
on October 18, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were seen by someone 
who just asked you a few questions and who was not a doctor. 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 $35 
copayment for a specialist office visit. The contract says Physician/practitioner services, including office visits, 
includes services performed by a PCP, specialist, physician assistant, or nurse practitioner. The medical record shows you had a visit with a nurse practitioner. According to the EOC, the same 
copayment amount applies if services were provided by a nurse practitioner. You have been asked to pay a $35 
copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, 
Including Doctor's 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 a 
pulmonary specialist office visit provided on October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for eye surgery performed on October 5, 
2021. 
 
You asked the Plan to waive the coinsurance for the eye surgery. You say that you were informed that the 
provider was in-network. 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 50% 
coinsurance for surgery with an out-of-network (OON) provider. 
 
 
 
 Service Allowed Amount 50% Coinsurance 
Pharmacy-General $124.92 $62.46 
Surgical Supplies $896.00 $448.00 
Intraocular Lens $279.11 $139.55 
Operating Room Services $2,464.76 $1,232.38 
Anesthesia $56.82 $28.41 
Total:  $1,910.80 
 
The file shows that the Plan has verified the provider is out-of-network. Therefore, you have been asked to pay 
$1,910.80, which is 50% of the allowed amount for the eye surgery. The eye surgery 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 coinsurance for eye surgery performed on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet the coverage 
criteria for the group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically reasonable and necessary. Records do not clearly show that you have tried and failed 
Orthovisc, Synvisc, or Synvisc One. The provided documentation does not describe you as having a 
contraindication to one or more of the preferred agents and it is not likely that these would be less effective or 
cause more adverse effects compared to Gelsyn-3 as comparative studies show essentially equal clinical 
effectiveness and safety between all hyaluronic agents in the same class. Our physician reviewer found that 
your condition does not meet step therapy criteria for Gelsyn-3. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on November 8, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a prior authorization, 
specifically for this member's play type at the time of rendering services. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider, and the referring provider is a non-participating provider with the Plan. The Plan also says 
that they did not authorize any services for the referring or rendering 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 drug testing 
(G0480) provided on November 8, 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 a specialist office visit (99214) and an 
ultrasound scanning of blood flow (outside the brain) on both sides of head and neck (93880) provided on 
August 24, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit and an ultrasound scanning of blood 
flow (outside the brain) on both sides of head and neck. You say that you have received several bills from this 
provider, the last saying you have a balance of $400, and you would like the Plan to please look at these bills to 
see if they have covered you on some of them. The Plan denied your request. The Plan says you were 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 $45 
copayment for services obtained from a specialist. Your contract with the Plan also clearly says that you must 
pay a $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed 
in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The Plan 
contract also says that the diagnostic radiology services require specialized equipment beyond standard x-ray 
equipment and must be performed by specially trained or certified personnel, and examples include, but are not 
limited to, ultrasounds for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctors office visits benefit category. You have also been asked 
to pay a $160 copayment for an ultrasound scanning of blood flow (outside the brain) on both sides of head and 
neck. An ultrasound scanning of blood flow (outside the brain) on both sides of head and neck 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 specialist office visit (99214) and an ultrasound scanning of blood flow (outside 
the brain) on both sides of head and neck (93880) provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided 
on October 24, 2021. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that the item should be 
covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the coinsurance applied correctly based on the item 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen concentrator (allowed is $97.03 x 20% = 
$19.41). Oxygen concentrators fall 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 an oxygen concentrator (E1390) provided on 
October 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
November 19, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford the 
copayments. 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 $35 
copayment for each therapy visit.  
 
You have been asked to pay a $35 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical therapy (PT) services provided on November 19, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a blepharoplasty of the upper eyelid 
provided on November 9, 2021. 
 
You asked the Plan to reduce the copayment for the blepharoplasty. You say that you had confirmed with the 
insurance company the procedure was being done at a surgical center. You also say you were told it was a $295 
copayment at a surgical center and a $345 copayment at a hospital. 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 $345 
copayment for outpatient surgery at an outpatient hospital.  
 
 The record shows the surgical procedure you had was performed at an outpatient hospital on November 9, 
2021. You have been asked to pay $345 copayment for a blepharoplasty. A blepharoplasty 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 reduce the copayment for a blepharoplasty of the 
upper eyelid provided on November 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford the 
copayments. 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 $35 
copayment for each therapy visit.  
 
 
 
 
 
  
You have been asked to pay a $35 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on November 16, 2021.