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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 11, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that this was due to an 
accident and you should not need to pay this copay. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency 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 an emergency room visit 
provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 19, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you feel the services should be covered because the 
facility claim with the same date of service was paid. The Plan denied your request. The Plan says an 
authorization was not obtained prior to services 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 an office visit provided on October 19, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
May 19, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you paid for a 
specialist visit so should not have to pay the copayment for the outpatient hospital visit. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $375 
copayment for outpatient hospital services.  
 
You have been asked to pay a $375 copayment for an outpatient hospital visit. The total amount you are being 
asked to pay is $146.30. This is less than the required amount. 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 outpatient hospital visit provided on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection provided on August 01, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that these services were covered 
previously. The Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for surgery services in an outpatient hospital. 
 
You have been asked to pay a $250 copayment for the injection. This item/service falls within the surgery 
services in an outpatient hospital 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 injection provided on August 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a golf membership purchased on July 1, 2022. 
 
You asked the Plan to pay for a golf membership. You say that every time you go to golf you walk at least 1.5 
miles for nine holes, or 3 plus miles for 18 holes, and you do this four to five times per week. You also say that 
this is a very good fitness plan and do not understand why the Plan would deny your request for 
reimbursement. The Plan denied your request. The Plan says the Plan does not reimburse for a golf 
membership. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the membership is with a gym or with weight watchers. 
 
 
  The Plans rules for coverage of gym benefits have not been met because golf memberships are not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for a golf membership purchased on July 1, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Pembrolizumab (Keytruda) is not FDA 
approved for microsatellite instability (MSI) stable colorectal cancer. Use is not supported by major drug 
compendia or the medical literature based on the enrollee's marker profile. Programmed cell death ligand 1 
(PDL1) is not used for colorectal cancers. The service is not reasonable or medical 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 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 lab testing provided on June 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy provided 
on June 14, 2022. 
 
You asked the Plan to waive the copayment for the fine needle aspiration biopsy. You say that the coding was 
incorrect and should not be billed as surgery. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $300 
copayment for outpatient surgery or procedure at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for the fine needle aspiration biopsy. This item/service falls 
within the outpatient surgery or procedure at an outpatient hospital 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 fine needle aspiration biopsy provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery provided on July 13, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the eye surgery. You say that the procedure was very helpful with this provider. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered by an out-of-network 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 eye surgery provided on July 13, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab pathology provided on July 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab pathology. You say that the patient never went to the lab, the specimens 
taken were sent there. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 lab pathology provided on July 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an endoscopy (EGD) provided on August 
18, 2021. 
 
You asked the Plan to reduce the copayment for an endoscopy (EGD). You say that you were told that if your 
primary care provider wrote a letter the copayment would be reduced. The Plan denied your request. The Plan 
says this cost sharing was charged 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for an endoscopy (EGD). This item/service 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 reduce the copayment for an endoscopy (EGD) provided 
on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 22, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says it is important to know which providers are part of our network because, with 
limited exceptions, while the enrollee is a member of our plan the enrollee must use network providers to get 
their medical care and services. The only exceptions are emergencies, urgently needed services when the 
network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and 
cases in which CareNeeds PLUS (HMO D-SNP) authorizes use of out-of-network providers. See Chapter 3 
(Using the plan's coverage for your medical services) for more specific information about emergency, out-of-
network, and out-of-area coverage. 
 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 lab testing provided on June 22, 2022, 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 therapeutic lightbox (E0203). 
 
You asked the Plan to pre-approve a therapeutic lightbox (E0203). You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a therapeutic lightbox is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic lightbox is not covered by 
Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a therapeutic lightbox have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic lightbox (E0203).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) device and humidifier provided on July 28, 2022. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure (CPAP) device and 
humidifier. You say that the provider failed to adjust the machine to make it useable. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous positive airway pressure (CPAP) device and 
humidifier. This item/service falls 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 coinsurance for the continuous positive airway pressure 
(CPAP) device and humidifier provided on July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for procedure code 23430. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 23430 is bundled into payment for code 23472. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 23430 is a column II code to column I code 23472. While code 
23430 was billed with modifier -59, the medical records provided do not show that this service billed with the  
-59 modifier is a distinct procedural service. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 23430 billed for date of 
service January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visits provide on March 9, 
2022, to March 29, 2022. 
 
You asked the Plan to waive the copayment for urgent care visits. You say that you feel that your spouse was 
misdiagnosed so your spouse should not have to pay the copayment. The Plan denied your request. The Plan 
says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment per visit for Urgently needed services.  
 
The enrollee has been asked to pay a $40 copayment per visit for urgent care visit. This item/service falls 
within the Urgently needed services benefit category. The total amount you are being asked to pay is $80 ($40 
x 2 visits = $80) 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 urgent care visits provide on 
March 9, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided from February 21, 2022, to June 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that a referral is not required per the website. The Plan 
denied your request. The Plan says while a referral is not required, the out-of-network benefits only apply to 
dental services. Authorization was not obtained prior to 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 office visits provided from February 21, 2022, to 
June 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on January 04, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you feel you were charged this 
copayment in error. You have had this procedure before and not had a copayment. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an injection. This item/service 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 an injection provided on January 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on August 10, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for an office visit.  
 
You have been asked to pay a $30 copayment for an office visit. This item/service falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit on August 10, 2022.