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

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal (eg, renal, aorta, nodes) 
ultrasound (76775) provided on November 26, 2021. 
 
You asked the Plan to waive the copayment for a retroperitoneal (eg, renal, aorta, nodes) ultrasound. You say 
that you paid the required $15 copayment, and you are being billed another $39.75. You also say that you want 
to know why the total of $54.75 is the member's responsibility? 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 $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 of medical clinic).  
 
You have been asked to pay $54.75, which is less than the $160 copayment for a retroperitoneal (eg, renal, 
aorta, nodes) ultrasound. A retroperitoneal (eg, renal, aorta, nodes) 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 a retroperitoneal (eg, renal, aorta, nodes) ultrasound (76775) provided on November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 2, 
2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider cancelled 
the appointment so you should not be held liable for services not rendered. The Plan denied your request. The 
Plan says that they obtained documentation for the date of service confirming service was rendered to the 
enrollee. Therefore, the proper copayment 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 
copayment for per visit for a Specialist office visit. The total amount allowed was $46.80 which is less than the 
copayment amount of $50. Therefore, only $46.80 was charged as the copayment. 
 You have been asked to pay a $46.80 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors 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 specialist office visit provided on June 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Outpatient Services on September 30, 
2021 to October 1, 2021. 
 
You asked the Plan to waive the copayments for Outpatient Services. You say that you do not have money for 
this. The Plan denied your request. The Plan says the copayment 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 $275 
copayment and a $110 copayment for Outpatient Services.  
 
You have been asked to pay a $275 copayment and a $110 copayment for Outpatient Services. Outpatient 
Services 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 copayments for Outpatient Services on September 30, 2021 to October 1, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional physical therapy visits. 
 
You asked the Plan to pre-approve 15 additional physical therapy visits. You say that you need these visits. The 
Plan denied your request. The Plan says these visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 15 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found you have had prior physical therapy and 
additional approved physical therapy to ensure proper transition to an independent home program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 15 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 15 additional physical therapy visits.
Appeal type: Outpatient Mental Health
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 November 30, 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 office visit (99214) rendered by the out-of-network (OON) provider on  
November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for debridement procedures of subcutaneous 
tissue provided on September 17, 2021, and October 1, 2021. 
 
You asked the Plan to reduce the copayments for debridement procedures. You say that you believed you were 
seeing a specialist because the office accepted your $20 copayment. You also say that you were not aware that 
this procedure had a copayment of $225 per visit. 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 $225 
copayment per visit for outpatient surgery at a hospital facility.  
 The record shows debridement of subcutaneous tissue is considered a surgical procedure. You have been asked 
to pay a $225 copayment for debridement procedures on September 17, 2021, and October 1, 2021. You have 
been asked to pay a total of $450 ($225 copayment + $225 copayment = $450). Debridement procedures 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 debridement 
procedures of subcutaneous tissue provided on September 17, 2021, and October 1, 2021.  
 
Your complaint about the providers office not telling you the correct copayment amount is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 22, 2021 to 
November 19, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services should be covered. 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 home health services provided on October 22, 
2021 to November 19, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is medically necessary as the 
enrollee is suffering from undernourishment and gastric conditions. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation  per quadrant (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are in disagreement on the decision made 
where the claim denied due to missing prior authorization. The Plan denied your request. The Plan says the 
referring provider is a non-participating provider, and the Plan did not authorize any services for this 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 laboratory services provided on November 10, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to remove excess tissue from the thigh (CPT 
code 15832). 
 
You asked the Plan to pre-approve the cosmetic surgery. You say that you have complaints related to excess 
skin of the bilateral thighs. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
 
 
 
 
 The service is a cosmetic procedure because it does not improve or restore physiologic function. Medicare nor 
your health plan covers cosmetic services. We looked at the file and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of the cosmetic surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve surgery to remove excess tissue from the thigh (CPT code 15832).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by 
the out-of-network (OON) provider on March 8, 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 targeted genomic sequence analysis (0037U) rendered by the out-of-network 
(OON) provider on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a follow up visit with irrigation of the 
bladder (51700) rendered on November 4, 2021. 
 
You asked the Plan to waive the copayment for a follow up visit with irrigation of the bladder. You say that 
you offered to pay a $45 copayment and the receptionist said there would be no charge since it was your first 
post operative visit after having your right kidney removed on October 27, 2021. 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 each specialist visit for Medicare-covered services.  
 
 You have been asked to pay a $45 copayment for follow up visit with irrigation of the bladder. A follow up 
visit with irrigation of the bladder falls within the physician/practitioner services, including doctors 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 follow up visit with irrigation 
of the bladder (51700) rendered on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-
network (OON) provider on September 4, 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 laboratory service (81479) rendered by the out-of-network (OON) provider on 
September 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agents would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary. The record indicates that the enrollee has osteoarthritis of the 
knee and has had received previous courses of therapy with other viscosupplementation agents. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternatives: Durolane, Monovisc, or Synvisc-One. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one 
alternatives. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Gel-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen based wound filler (A6010), gauze (A6219), and 
the alginate or other fiber gel dressing (A6199) rendered by the out-of-network (OON) provider on  
November 3, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items were 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 items at issue in this appeal. The Plan did not pre-approve the items at issue.  
We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the collagen based wound filler (A6010), gauze (A6219), and the alginate or other 
fiber gel dressing (A6199) rendered by the out-of-network (OON) provider on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 23, 2021. 
 
You asked the Plan to pay for the dental service. You say that you did not realize that you had back to back 
cleanings. You also say that if the provider had looked at your chart, they would have known that. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 2 prophylaxis procedures are 
covered per calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for 
prophylaxis that you received on May 11, 2021, and March 16, 2021. Therefore, we decided that the Plan does 
not have to pay for the prophylaxis (D1110) provided on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy, including 
ultrasound guidance (10005) provided on June 3, 2021. 
 
You asked the Plan to waive the copayment for a fine needle aspiration biopsy, including ultrasound guidance. 
You say that you received a bill from your provider for $300 outpatient copayment, but this has happened to 
you before. You also say the provider stuck a needle into your neck, took some material out and sent it to the 
lab. 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 $300 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.   
You have been asked to pay a $300 copayment for a fine needle aspiration biopsy, including ultrasound 
guidance. a fine needle aspiration biopsy, including ultrasound guidance falls within the Medicare-covered 
outpatient surgery in an ambulatory surgical center or hospital outpatient facility 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 fine needle aspiration biopsy, including ultrasound guidance 
(10005) provided on June 3, 2021.