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

 
We decided that the Plan does not have to pay for a specialist office visit and the removal of impacted cerumen 
provided on November 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit and the removal of impacted cerumen. You say that you 
have always called the Plan's customer service phone number, and in this case, you requested a number for an 
ear, nose, and throat doctor (ENT). You also say you would not have gone to an out-of-network because you 
have always called this Plan for referrals and telephone numbers, so you thought you were always getting 
correct information. The Plan denied your request. The Plan says they reviewed the call history and they do not 
have a record of the call where the customer service department provider you with this provider's name as an 
in-network provider, and there is no evidence of medical necessity. 
 
 
 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 removal of 
impacted cerumen provided on November 22, 2021, 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 the transthoracic echocardiography (93306) 
and the duplex scan of the extracranial arteries (93880) provided on January 24, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services 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 $200 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations with the exceptions 
indicated.  
  
 
You have been asked to pay a $200 copayment for the diagnostic ultrasounds provided. 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 transthoracic echocardiography (93306) and the duplex scan of 
the extracranial arteries (93880) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 25, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain the authorization, and the assisted living facility is responsible to obtain prior authorization for all of 
their patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the 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 domiciliary or rest home visit provided on 
October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the caloric vestibular test with recording, 
bilateral (92537) provided on March 24, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $225 
copayment per visit for outpatient surgery or procedure at an outpatient hospital.  
 
 
 You have been asked to pay $140.51 for the outpatient procedure provided at an outpatient hospital. This is the 
Plans allowed amount for this service, which is less than the applicable copayment. 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 adjust the copayment for the caloric vestibular test with recording, bilateral (92537) provided on March 24, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Humira. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says self-administered drugs are not a covered benefit. 
 
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 Humira.  
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adcetris, Ipilimumab, and Nivolumab. 
 
You asked the Plan to pre-approve Adcetris, Ipilimumab, and Nivolumab. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Adcetris, Ipilimumab, and Nivolumab. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the combination 
is not supported in phase III trials. This enrollee has already progressed on brentuximab and prior 
immunotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Adcetris, Ipilimumab, and Nivolumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Adcetris, Ipilimumab, and Nivolumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on December 
23, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were not informed of the 
difference in cost between an outpatient hospital and an ambulatory surgical center setting. The Plan denied 
your request. The Plan says the copayment 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment for Medicare-covered surgery services at a hospital outpatient facility.  
 
The enrollee has been asked to pay a $350 copayment for outpatient surgery. Outpatient surgery falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
December 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an eptinezumab injection and 
chemotherapy intravenous (IV) infusion provided on October 19, 2021. 
 
You asked the Plan to waive the coinsurance for an injection and IV infusion. You say that you spoke to a 
couple plan representatives who assured you that the services would be covered at 100% but are now getting a 
bill for the 20% coinsurance. 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 Part B drugs.  
 
 You have been asked to pay $966.55, which is 20% coinsurance of the allowed amount for an injection 
($4,832.76 allowed amount x 20% coinsurance = $966.55). You have also been asked to pay $77.61, which is 
20% coinsurance of the allowed amount for an IV infusion ($388.07 allowed amount x 20% coinsurance = 
$77.61). You have been asked to pay a total of $1,044.16 ($966.55 coinsurance + $77.61 coinsurance = 
$1,044.16). An injection and IV infusion 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 eptinezumab injection and chemotherapy intravenous 
(IV) infusion provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician visit provided on November 12, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician visit. You say that it is the responsibility of the hospital staff to 
receive authorization. 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 physician visit provided on November 12, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
leg provided on November 19, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford the copayment. 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 $150 
copayment for diagnostic and nuclear medicine radiological services other than mammograms and ultrasounds.  
 
You have been asked to pay a $150 copayment for the MRI. The MRI 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 magnetic resonance imaging (MRI) of the leg provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the 
out-of-network (OON) provider on December 7, 2021. 
 
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 psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) 
provider on December 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on November 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that authorization requests on the Plan's portal limits 
authorization for this service code to one unit/visit, and you are unable to request another authorization via the 
portal as any new request for the related service code will result in a denial for duplication. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained 
prior to the 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 home visit provided on November 20, 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 a domiciliary or rest home visit and chronic care 
management services provided on September 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and chronic care management services. You say 
that the assisted living facility is responsible to obtain prior authorization for all of their patients, which should 
also cover for the medical treatments provided by this provider. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan, and authorization was not obtained prior to the 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 domiciliary or rest home visit and chronic care 
management services provided on September 17, 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 October 
28, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were told in the hospital 
you would not be charged for the ambulance transport. The Plan denied your request. The Plan says the 
copayment 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 $175 
copayment for Medicare-covered one-way ground ambulance.  
 
You have been asked to pay $175 for the ambulance service. 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 October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (74177, 
71260, 78306) provided on August 18, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $150 copayment for a CT scan. CT scans 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 copayment 
for a computed tomography (CT) scan (74177, 71260, 78306) provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home health services provided on March 10, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Home health services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization is required for 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 Home health services provided on March 10, 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 services provided 
on September 21, 2019. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were 
transferred from one hospital to another for surgery. 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 per day for ambulance services.  
 
You have been asked to pay a $325 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 services provided on September 21, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the extremities provided 
on February 7, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that it was your understanding that you 
had no charges for follow up procedures. You also say that you cannot afford $75 per scan especially since you 
had no idea you were liable for that. 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 $75 
copayment for an ultrasound.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$75 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 extremities provided on February 7, 2022.