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

 
We decided that the Plan does not have to waive the copayment for the ophthalmological medical examination 
and evaluation with initiation of a diagnostic and treatment program (92004) provided on December 8, 2021. 
 
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 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 $35 
copayment per Medicare-covered eye exam.  
 
You have been asked to pay a $35 copayment for the Medicare-covered eye exam 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 ophthalmological medical examination and 
evaluation with initiation of a diagnostic and treatment program (92004) provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tubing with heating element (A4604) 
provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for the tubing. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied correctly based 
on the item provided. The provider has indicated that the tubing was not returned with the mask, therefore, the 
coinsurance still applies. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
You have been asked to pay a 20% coinsurance for the tubing (allowed is $47.75 x 20% = $9.55). Tubing items 
fall within the Durable medical equipment (DME) and related supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for tubing with heating element (A4604) provided on November 12, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on September 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility requested you to address the 
enrollee's medical needs. Therefore, it was medically necessary to treat the enrollee. The Plan denied your 
request. The Plan says during the date of service the rendering provider was an out-of-network provider and 
there was no approved authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 health visit provided on September 30, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says documentation of a trial with a basic pump was not shown. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not show the patient having characteristics that would warrant segmented pump 
over a standard pump. The documentation does not clearly show the patient having tried and failed a standard 
pump.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (code 93005) 
provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the electrocardiogram (code 93005). You say that the 
electrocardiogram was done during the office visit. The Plan denied your request. The Plan says the copayment 
amount 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $110 copayment for basic radiological services provided at an outpatient hospital.  
 
 
 
 
 The enrollee has been asked to pay $29, which is less than the Plan's EOC documented $110 copayment for an 
electrocardiogram (code 93005). An electrocardiogram (code 93005) falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 the electrocardiogram (code 93005) provided on December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) of the chest 
provided on January 20, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not have a $60 patient 
responsibility 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 $60 
copayment for each complex diagnostic radiological service, including CT scans.  
 
 You have been asked to pay a $60 copayment for a CT scan. A CT scan falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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) of the chest provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 24, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and the service was rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider 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 a home health visit provided on November 24, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided and on September 
27, 2021. 
 
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says 
this item is not a covered benefit.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on September 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a parathyroidectomy (60500) provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the parathyroidectomy. 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 $125 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $125 copayment for a parathyroidectomy. The parathyroidectomy falls within 
the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a parathyroidectomy (60500) 
provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management injection provided on August 10, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pain management injection. You say that the services were medically 
necessary and should be covered by the Plan. 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 pain management injection provided on 
August 10, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 11, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
member has other insurance and the Plan was unable to get the explanation of benefits (EOB) to reprocess the 
claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has been unable 
to obtain the EOB. As the secondary insurer, the Plan cannot be held responsible for the emergency department 
visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does 
not have to pay for an emergency department visit provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
22, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you were never charged 
for lab services before. 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 $10 per 
day for laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for the laboratory services. The laboratory 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 copayment for laboratory services provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health services provided from 
September 7, 2021, to September 17, 2021. 
 
You asked the Plan to waive the copayment for the mental health services. You say that you didnt receive 
these services. The Plan denied your request. The Plan says the copayment applied 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 $25 
copayment for mental health services in a specialists office.  
 
 
 
 You have been asked to pay $200 for the mental health services ($25 copay x 8 dates of services). The mental 
health services fall within the Outpatient mental health 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 the mental health services provided from September 7, 2021, to September 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical injections (64483) 
provided from February 12, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgical injections. 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 $250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $1,250 copayment for 5 outpatient surgical injections ($250 x 5 = $1,250). 
Outpatient surgical injections fall within the Outpatient hospital 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 outpatient surgical injections (64483) provided from February 12, 
2021, to November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infliximab injection (Q5103) provided 
from June 17, 2021, to November 3, 2021. 
 
You asked the Plan to waive the coinsurance for the infliximab injection. You say that the services should be 
covered as they were ineffective. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for four infliximab injections ($971.42). Infliximab injections 
fall 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 infliximab injection (Q5103) provided from June 17, 2021, to November 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on June 1, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that another claim for a different date of service 
for the same procedure was partially paid. 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. The Plan also 
says that the referring provider was out-of-network with the Plan, and the services rendered were not Plan 
directed care. The Plan also says that regarding the appellant's statement that the Plan paid for similar services 
rendered on June 1, 2021, the Plan reviewed their records and determined that the claim for services rendered 
on June 1, 2021, was denied for no authorization, which is now being appealed, and there is no record of a paid 
claim for February 5, 2021.  
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 speech/hearing therapy (92507) provided on June 
1, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says the record shows this scooter is for use outside the home, and it is 
therefore non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0800).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 8, 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 by the Plan. 
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 September 8, 
2021 by an out-of-network (OON) provider.