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

 
We decided that the Plan does not have to waive the copayment for office visit on August 24, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that even though your doctor scheduled a 
visit with you, but some other doctor did the procedure, completely out of your hands. The Plan denied your 
request. The Plan says the cost-sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copay for office visits to specialist at an independent office. Covered services include: Medically-necessary 
medical care or surgery services furnished in a physicians office, certified ambulatory surgical center, hospital 
outpatient department, or any other location. Consultation, diagnosis, and treatment by a specialist. 
 
 
 
 
 
 You have been asked to pay a $45 copayment for office visit. 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 office visit on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frame and lens services provided on February 17, 2022. 
 
  You asked the Plan to pay for the frame and lens services. You say that you believe you were not provided with 
your full vision benefits in accordance with the Plans 2022 Evidence of Coverage. You also say that you 
believe the Plan owes you $80.00. The Plan denied your request. The Plan says this claim was processed 
correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 toward the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses per calendar year. 
 
We looked at the file and the Plan's rules. The record shows the total for the glasses was $510, minus the Plan's 
$200 allowance which equals $310. You were also offered a 20% discount ($62) leaving you responsible for a 
total of $248 for the glasses. Based on this information, we decided that the Plan's rules for coverage of the 
frame and lens services have not been met. Therefore, we decided that the Plan does not have to pay for the 
frame and lens services provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on January 19, 2022 by an 
OON provider. 
 
You asked the Plan to pay for a psychotherapy visit. You say that the treatment was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 psychotherapy visit provided on January 19, 
2022 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on January 17, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior 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 
subsequent hospital care. We found no exception that would require the Plan to pay for the subsequent hospital 
care. The records provided for review do not show that the subsequent hospital care was urgent or emergent. Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided on January 17, 
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 office visit provided on January 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 21, 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 outpatient office visit provided on February 11, 2022, by 
an out-of-network provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you would like this service covered. The 
Plan denied your request. The Plan says the enrollee went to an out-of-network provider and services 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 outpatient office visit provided on February 
11, 2022, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a PET scan and chemotherapy drugs 
provided from August 3, 2021, to September 22, 2021. 
 
You asked the Plan to waive the cost share for PET scan and chemotherapy drugs. You say that you don't pay 
out of pocket that these costs should be covered. The Plan denied your request. The Plan says the cost share 
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 $80 
copayment for radiological services and 20% coinsurance for Medicare covered Part B Drugs. 
 
You have been asked to pay $80 copayment for the PET scan and $179.60 which is 20% of the allowed amount 
for the chemotherapy drugs. The allowed amount is $83 ($83 x 20%= $16.60). You were given these drugs six 
times ($16.60 x 6= $179.60). The total amount you must pay is $259.60. Chemotherapy drugs fall within the 
Medicare Part B Prescription Drugs benefit category and the PET scan 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 cost share 
for a PET scan and chemotherapy drugs provided from August 3, 2021, to September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive your $65 copayment for an Urgent Care visit on March 24, 2022. 
 
You asked the Plan waive your $65 copayment for an Urgent Care visit on March 24, 2022. You say that you 
should not have to pay this copayment because the doctor did not examine you. The Plan denied your request. 
The Plan says you are responsible to pay a $65 copayment for this service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for Urgently Needed Services.  
 
You have been asked to pay a $65 copayment for an Urgent Care visit. An Urgent Care visit falls within the 
Urgently Needed 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 waive your $65 copayment for an 
Urgent Care visit on March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of leg without 
contrast (73700). 
 
You asked the Plan to pre-approve a CT scan of leg without contrast. You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says the service at issue is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of leg without contrast. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found open conventional 
knee replacement is the gold standard and computer assist surgery is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of leg without contrast have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) scan of leg without contrast (73700).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a retroperitoneal ultrasound provided on 
January 28, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that your copayment should only be 
the $15 you paid on that day. 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 $110 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $104.09, which is less than the $110 copayment for the ultrasound. The 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 reduce the copayment for a retroperitoneal ultrasound provided on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $30.11 copayment for psychological or 
neuropsychological testing performed on February 9, 2022. 
 
You asked the Plan to waive your $30.11 copayment for psychological or neuropsychological testing 
performed on February 9, 2022. You say that you should not be responsible for this copayment. The Plan 
denied your request. The Plan says you must pay a $40 copayment. 
 
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 $40 
copayment for Outpatient Mental Health Care.  
 
You have been asked to pay a $30.11 copayment for psychological testing. Psychological or 
neuropsychological testing 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. The submitted amount was $112; the Plans allowance was $30.11. This means that you have been 
asked to pay less than your contracted amount 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 your $30.11 copayment for psychological or 
neuropsychological testing performed on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a remote physiologic monitoring treatment provided on 
January 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a remote physiologic monitoring treatment. You say that you are requesting 
reconsideration stating you disagree with the denial. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
 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 remote physiologic monitoring treatment 
provided on January 31, 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 subsequent hospital care provided on January 6, 2022, to 
January 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior 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 
subsequent hospital care. We found no exception that would require the Plan to pay for the subsequent hospital 
care. The records provided for review do not show that the subsequent hospital care was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided on January 6, 
2022, to January 7, 2022, 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 transport provided on December 
21, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you thought you would be 
treated faster if you arrived by ambulance, this was not true so it should be covered. 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 $225 
copayment for each one-way Medicare-covered ambulance trip. 
 
You have been asked to pay $225 copayment for ambulance transport. Ambulance transport 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 transport 
provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
23, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you already paid for an 
office visit and should not have to pay again. 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 $35 
copayment for each Medicare covered specialist office or telehealth visit.  
 
You have been asked to pay $35 copayment for specialist office visit. Specialist office visits fall 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 specialist office visit provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that your condition affects normal daily 
activities. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because you do not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that thermal radiofrequency ablation of a facet joint is 
only covered if certain criteria 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 facet joint injections. Our reviewer says 
that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found 
the second set of medial branch blocks did not produce greater than 80% pain relief, so radiofrequency ablation 
(RFA) is not indicated. There is no role for repeated diagnostic medial branch blocks, so this request is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from November 29, 2021, through 
January 31, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider is not 
eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
November 29, 2021, through January 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darbepoetin. 
 
You asked the Plan to pre-approve Darbepoetin. You say that this is medically necessary. The Plan denied your 
request. The Plan says that iron stores are below goal and need to be repleted before Darbepoetin therapy is 
considered. 
 
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 Darbepoetin. Our reviewer says that 
Darbepoetin is not medically reasonable and necessary. Due to the lack of sufficient iron stores, therapy is not 
indicated. After iron stores are made replete then therapy will be appropriate. Our physician reviewer found 
that your condition does not meet criteria for coverage of Darbepoetin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darbepoetin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darbepoetin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from February 3, 2022, 
through February 17, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the acupuncture provided was not for treating chronic low back 
pain as required by Medicare rules. 
 
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.  
 
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, this claim has been submitted with a diagnosis of M54.2 defined as cervicalgia. There is no 
evidence provided that the services rendered were for chronic low back pain. Therefore, we decided that the 
Plan does not have to pay for the acupuncture services provided from February 3, 2022, through February 17, 
2022.