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

 
We decided that the Plan does not have to reduce the copayments for back injections performed on December 
14, 2021, and February 1, 2022. 
 
You asked the Plan to reduce the copayments for the injections. You say that your copayments should only be 
$35 for specialist visits. 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 surgery or services provided at an outpatient hospital.  
 
The file shows that the services were billed with a hospital outpatient facility location code. Therefore, you 
have been asked to pay a $250 copayment for each of the injections, for a total of $500. The injections fall 
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 copayments for back injections 
performed on December 14, 2021, and February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. 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 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 drug testing provided on November 18, 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 transportation provided on April 
13, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should only 
have one copayment since it was one trip. 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 $300 
copayment for each one-way ambulance service.  
 
The file shows that only one copayment was applied for the air ambulance service. Therefore, you have been 
asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 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 
transportation provided on April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Acetaminophen and Loratadine provided on September 
3, 2021. 
 
You asked the Plan to pay for the Acetaminophen and Loratadine. The Plan denied your request. The Plan says 
Acetaminophen and Loratadine are self-administered drugs, and are not Part B covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for 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 pay for the Acetaminophen and 
Loratadine provided on September 3, 2021.  
 
Benefits for the Acetaminophen and Loratadine may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, 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 March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency stretcher van transportation (T2005) 
provided on February 6, 2022. 
 
You asked the Plan to pay for the non-emergency stretcher van transportation. The Plan denied your request. 
The Plan says neither Original Medicare nor the Health Plan cover transportation services in stretcher vans. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when you are transported by wheelchair, taxi, or sedan 
transportation vehicles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for the non-emergency stretcher van transportation (T2005) provided on February 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a home oxygen unit on December 22, 
2021. 
 
You asked the Plan to waive the coinsurance for a home oxygen unit. You say that you should not have to pay 
this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was correct. 
 
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). The allowed amount of this service is $136.32 resulting in 
a coinsurance amount of $27.26 ($136.32 x 20% = $27.26). 
 
You have been asked to pay a 20% coinsurance for a home oxygen unit. A home oxygen unit falls within the 
Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a home oxygen unit on December 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on March 09, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that this service was not 
available anywhere else and feel that you should not be liable for a $90.00 copayment. You would like the plan 
to pay this claim in full. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
correct. 
 
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 $90 
copayment for each emergency room visit. Emergency care refers to services that are: Furnished by a provider 
qualified to furnish emergency services, and needed to evaluate or stabilize an emergency medical condition.  
 
 
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 emergency 
room services on March 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 17, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that according to the Evidence of Coverage, eye 
refractions are a covered service in all plans. The Plan denied your request. The Plan says this service is not a 
covered benefit since it was medical vision check. The Plan also says that eye refractions are only covered by 
your plan if performed by a participating provider and performed as a routine screening. 
 
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 it is performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that this eye refraction was performed during a 
medical vision check for other secondary cataract, bilateral. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction (92015) provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020) provided on April 14, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyeglass frames. You say that you went to an in-network provider but were 
quoted $566 for glasses, so you decided to go elsewhere. You also say that it was much less to go to the OON 
provider. The Plan denied your request. The Plan says the provider that performed this service is not in the 
Plan's network. The Plan also says while you are a member of the Plan, you must use network providers to get 
your medical care and services. 
 
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 rendered by a network provider. 
 
We looked at the file and the Plan's rules. The record shows that these eyeglass frames were rendered by an 
OON provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglass frames 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass frames (V2020) 
provided on April 14, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
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 end-stage renal disease. 
He has not tried and failed the Plan's required drug, Mircera. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Aranesp 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 Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX bladder detect test provided on January 26, 2022. 
 
You asked the Plan to pay for the CX bladder detect test. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for CxBladder is not covered. 
 
We looked at the file and Medicare rules. The services rendered are specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of the CX bladder detect test have not been met. 
Therefore, we decided that the Plan does not have to pay for the CX bladder detect test provided on January 26, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gattex. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for 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 pre-approve Gattex.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on April 8, 2021, to August 12, 
2021, at an out-of-network (OON) facility. 
 
You asked the Plan to pay for the office visits. You say that you were told in 2020 that the physician is in-
network. The Plan denied your request. The Plan says the services were provided at an out-of-network facility 
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 visits provided on April 8, 2021, to 
August 12, 2021, at an out-of-network (OON) facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on January 
12, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the optometrist you were treated by 
is in-network. The Plan denied your request. The Plan says the copayment for services rendered is being 
assessed correctly per the Plan benefits and how the provider coded the claims submission. 
 
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 Vision Services.  
 
You have been asked to pay a $65 copayment for the eye exam. The eye exam falls within the Vision Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the eye exam (92014) provided 
on January 12, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the neuromuscular reeducation (97112),  
x-ray exam of the lumbar spine (72100), and the x-ray exam of the cervical spine (72040) provided from  
January 24, 2022, through March 11, 2022. 
 
You asked the Plan to issue reimbursement for these services. 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 at 
issue are not payable when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the neuromuscular reeducation (97112), x-ray exam of 
the lumbar spine (72100), and the x-ray exam of the cervical spine (72040) provided from January 24, 2022, 
through March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 11, 2022, 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 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 an office visit provided on February 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism provided on October 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a seat lift mechanism. You say that you would like to request reconsideration of 
the denied claim. 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 a seat lift mechanism provided on October 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography, of the heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that you have elevated cholesterol but you do 
not have symptoms suggestive of cardiac disease. The stress echocardiogram provided was negative for 
Ischemia. The Center for Medicare and Medicaid Services (CMS) does not cover screening tests such as 
coronary calcium scoring in asymptomatic patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography, of the heart, without contrast material, with quantitative evaluation 
of coronary calcium (75571).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided March 28, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you needed assistance but did not require 
transport. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 28, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided March 28, 2022.