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 at urgent care facility provided 
on July 03, 2022. 
 
You asked the Plan to waive the copayment for office visit at urgent care facility. You say that you do not 
understand why you had to pay for a COVID-19 vaccine. 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 $40 
copayment for Urgently needed services. 
 
You have been asked to pay a $40 copayment for office visit at urgent care facility. This item/service 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 to waive the copayment for 
office visit at urgent care facility provided on July 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 02, 2022. 
 
You asked the Plan to pay for office visit. You say that you did not realize you needed authorization to see the 
provider because they are not a specialist. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that the 
medical records provided support the need for the requested CGM. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on September 09, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on September 09, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the intravenous hydration infusion (96360) and complete bilateral study 
(93970) provided on July 26, 2021. 
 
You asked the Plan to pay for the intravenous hydration infusion and complete bilateral study. You say that the 
denied services were clearly medically necessary, and this claim should be reprocessed accordingly. The Plan 
denied your request. The Plan says that the service does not meet the coverage requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records submitted do not include any evidence to support how the service at 
issue was initially billed or why it was denied. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the intravenous hydration infusion (96360) and complete 
bilateral study (93970) provided on July 26, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 03, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
June 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pessary, non-rubber, any type as 
maintained by CMS falls under Various Medical Supplies Including Tapes and Surgical Dressings (A4562) x4, 
initial fitting for A4562 (57160), insertion of non-indwelling bladder catheter (51701), and office visit (99212) 
provided on July 26, 2022, to August 24, 2022. 
 
You asked the Plan to waive the copayment for services billed under codes A4562, 57160, 51701 and 99212. 
You say that you do not feel you should be charged for the visits being appealed. 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 the cost for each Medicare-covered item and $40 copayment for each specialist office visit for 
Medicare-covered service. 
 
You have been asked to pay $122.36 for services billed under codes A4562, 57160, 51701 and 99212.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 26, 2022 Initial fitting for 
A4562 
$62.53 $40 $40 
July 26, 2022 Pessary, non-
rubber, any type  
$52.96 20% $10.59 
August 17, 2022 Pessary, non-
rubber, any type  
$52.96 20% $10.59 
August 23, 2022 Pessary, non-
rubber, any type  
$52.96 20% $10.59 
August 24, 2022 Pessary, non-
rubber, any type 
$52.96 20% $10.59 
August 24, 2022 Insertion of non-
indwelling bladder 
catheter and Office 
visit 
$37.43 /$46.74 $40 $37.43 + 
$2.57=$40 
TOTAL:    $122.36 
 
Pessary, non-rubber, any type (A4562) falls within the Durable medical equipment (DME) and initial fitting for 
A4562 (57160), insertion of non-indwelling bladder catheter (51701), and office visit (99212) 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 pessary, non-rubber, any type as maintained by CMS falls under Various Medical 
Supplies Including Tapes and Surgical Dressings (A4562) x4, initial fitting for A4562 (57160), insertion of 
non-indwelling bladder catheter (51701), and office visit (99212) provided on July 26, 2022, to August 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 2, 2022, to January 
15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says services should be provided by an in-network provider. 
There is no prior authorization on file for the 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 nursing facility care provided on January 2, 2022, 
to January 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 18, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatology visit provided by an in-
network provider on September 7, 2022. 
 
You asked the Plan to waive the copayment for the dermatology visit. You say that you believe the wrong 
billing code was used. 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 $35 
copayment for in-network services obtained from a specialist in a specialists office. 
 
You have been asked to pay a $21.47 copayment for the dermatology visit because the allowed amount for this 
service is less than $35. 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 the dermatology visit 
provided by an in-network provider on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 provided on May 20, 2022. 
 
You asked the Plan to pay for procedure code 87506. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing 
of code 87506. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87506 is Infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the medical records show 
that 16 infectious agents were tested. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87506 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87506 provided on May 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic services provided on August 8, 
2022, to September 14, 2022. 
 
You asked the Plan to waive the copayment for therapeutic services. You say that you are disputing the share 
cost. 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 $40 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay $40 copayment for each therapeutic service. This item/service falls within the 
outpatient rehabilitation 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 
therapeutic services provided on August 8, 2022, to September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 25, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on 
August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2022. 
 
You asked the Plan to pay for laboratory services. You say that services were medically necessary and related 
to the members diagnosis. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 08, 2022. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care services 
provided on September 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic lab testing provided on September 21, 2022. 
 
You asked the Plan to pay for genetic lab testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic lab testing 
provided on September 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport provided 
on December 1, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that the fire 
department never stated there was going to be a charge for checking your vitals. You also say had you known, 
you could have done them as you have your own equipment. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 2, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the records attached support the 
services being rendered. The Plan denied your request. The Plan says there is no referral or authorization from 
the primary care provider on file for the services provided. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
August 2, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orencia (J0129). 
 
You asked the Plan to pre-approve Orencia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Orencia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Remicade, infliximab, Inflectra or Simponi Aria before they will approve the 
requested drug, Orencia. There is no indication in the available medical records that the enrollee has tried and 
failed the required drugs. Based on the medical records provided and the Medicare-approved major drug 
compendia, there is no indication that the Plan's required drugs would likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Orencia (J0129).