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

 
We decided that the Plan does not have to pay for telemedicine services provided on March 17, 2021. 
 
You asked the Plan to pay for telemedicine services. The Plan denied your request. The Plan says authorization 
is required for non-contract providers and no authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 telemedicine services provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your contract with the Plan requires the claim to be 
paid as a routine matter. The Plan denied your request. The Plan says the rendering and referring providers are 
both OON providers 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 February 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you do not like the in-network 
specialist and would like a referral to an OON provider. The Plan denied your request. The Plan says there is 
already an approved authorization for a different in-network provider and a list of multiple in-network 
providers that provide the same quality of service was given to the enrollee. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an extended manufacturer warranty for hearing 
aids provided on January 17, 2022. 
 
You asked the Plan to reimburse you for an extended manufacturer warranty for hearing aids. The Plan denied 
your request. The Plan says an extended manufacturer warranty is not medically necessary and not a covered 
benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan covers hearing aids; however, there is no 
coverage for a manufacturer warranty. Therefore, we decided that the Plan does not have to reimburse you for 
an extended manufacturer warranty for hearing aids provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Orthovisc injection provided on 
October 28, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have met your maximum out-
of-pocket. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Part B drugs. The Plan contract also says that enrollees must pay a $6,900 
maximum out-of-pocket (MOOP) per calendar year. 
 
The record shows the cost share for this injection was applied to your maximum out-of-pocket as it had not 
been met at the time of the injection. You have been asked to pay $609.16, which is 20% coinsurance of the 
allowed amount for an injection ($3,045.82 allowed amount x 20% coinsurance = $609.16).  An injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an Orthovisc injection provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. 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 May 19, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 11, 2021. 
 
You asked the Plan to reimburse you for hearing aids. You say that you do not like the cost of hearing aids 
offered through the Plan's hearing provider. The Plan denied your request. The Plan says hearing aids are 
covered through the Plan's hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only through the Plan hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided through the 
Plans hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing 
aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on January 19, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on January 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 20, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that this visit should have been 
processed as an outpatient vision care physician service, and the copayment should be waived. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 $25 
copayment for each Medicare-covered specialist visit.  
 
 
 You have been asked to pay a $25 copayment for an office visit. The 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 an office visit provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychosocial rehabilitation services provided from March 
7, 2022, to March 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychosocial rehabilitation services. You say that you would like the claims 
reprocessed and the service provided to the enrollee was medically necessary and the service provided does not 
need prior authorization. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an 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 the psychosocial rehabilitation services provided 
from March 7, 2022, to March 11, 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 an office visit provided on June 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and 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 June 2, 2021 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 provided on May 21, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory to process, and the referring physician is an in-network provider. The Plan denied your request. 
The Plan says the rendering and referring providers are both OON providers 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 the laboratory services provided on May 21, 2021, 
by an out-of-network (OON) provider.
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 you disagree with the plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have bilateral knee pain related to osteoarthritis. The documentation does not support that you have 
tried and failed Monovisc, Orthovisc or Synvisc/Synvisc-One. The documentation does not support an 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for 
you. Therefore, you do not meet criteria for the requested drug. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response services provided on June 11, 2021. 
 
You asked the Plan to pay for the ambulance response services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says you were not transported by 
ambulance on June 11, 2021, as the provider billed ambulance response services with 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 June 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response services provided on June 
11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of a power seat lift chair. 
 
You asked the Plan to pre-approve replacement of a power seat lift chair. You say that the requested 
replacement power seat lift chair is medically necessary. The Plan denied your request. The Plan says the 
requested replacement power seat lift chair is not medically necessary.  
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve replacement of a power seat lift chair. 
Our reviewer says that the requested replacement power seat lift chair is not medically necessary. Our 
physician reviewer found provided records document unspecified arthritis; no neuromuscular disease is 
documented. The provided records do not clearly document that a seat lift is included in a treating practitioner's 
(physician's or advanced practice provider's) course of treatment. There are no provided records from a 
physician or advanced practice provider clarifying that the requested seat lift mechanism will affect 
improvement in the enrollee's condition or arrest or retard deterioration in the enrollee's condition. The enrollee 
is reported to require assistance with all transfers including chair transfers. The records show that the enrollee 
can ambulate slowly with a walker. At this time, the enrollee does not meet criteria for the requested 
replacement power seat lift chair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement of a power seat lift chair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve replacement of a power seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Podiatry services provided on January 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Podiatry services. 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 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 Podiatry services provided on January 11, 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 the acupuncture services for your neck pain provided from 
December 10, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the acupuncture services for your neck pain. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for the acupuncture services provided as there is no documentation showing the acupuncture 
services were to treat chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows you received acupuncture services to 
treat neck pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services for your 
neck pain provided from December 10, 2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 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 10, 2022 by 
an out-of-network (OON) provider.