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

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion to be provided by an OON provider. You say that you 
would like the Plan to reconsider their denial as you have a very rare aggressive cancer. The Plan denied your 
request. The Plan says there are equally qualified in-network tertiary (higher-level) facilities and providers 
available to you that can provide you with a second opinion. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammography provided on December 21, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a mammography. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 mammography provided on December 21, 2021 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the enrollee has moderate left 
knee tricompartmental osteoarthritis (OA) changes on x-ray, most pronounced medially, and has failed 
analgesics. There is however no documentation of having tried and failed conservative non-pharmacological 
management, such as bracing and physical therapy. The review has determined that the documentation does not 
support that Euflexxa is medically reasonable and necessary for the enrollee. The documentation does not 
support that Euflexxa is safe and effective 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from November 19, 2021, to December 10, 2021.  
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you were 
transferred internally for rehabilitation. You also say that this should be covered under the initial hospital stay 
and should not receive a separate bill for each. 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 $160 
copayment per day for days 1-5 for an inpatient rehabilitation stay. The Plan contract also says that there is a $0 copayment for days 6-90. The contract says if you are discharged from one level of care and readmitted to 
another level of care, separate copayments will apply. 
 
The medical record shows that you were discharged after surgery and remitted for rehabilitation on November 
19, 2021. According to the EOC, a separate copayment will apply if you are discharged from one level of care 
and readmitted to another level of care. You have been asked to pay a $160 copayment per day for days 1-5 for 
an inpatient rehabilitation stay from November 19, 2021, to December 10, 2021 ($160 copayment x 5 days = 
$800). An inpatient rehabilitation stay falls within the Inpatient Hospital 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 inpatient rehabilitation stay provided from November 19, 2021, to 
December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclosporine. 
 
You asked the Plan to pre-approve Cyclosporine. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Cyclosporine is not covered under the enrollee's Medicare 
Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclosporine.  
 
Benefits for Cyclosporine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says as per 
the review of the denied claim the Plan found that the non-urgent services are not authorized because this 
provider is a non-network provider with the Plan. The Plan also says that the member's network primary care 
physician (PCP) did not refer for services. 
 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 subsequent nursing facility care provided on 
November 17, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for ultrasound and office visit provided on 
February 16, 2022. 
 
You asked the Plan to waive the cost share for ultrasound and office visit. You say that the provider will accept 
Medicare payments in full. The Plan denied your request. The Plan says the coinsurance 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic) and $20 
copayment for services obtained from a specialist.   
You have been asked to pay $106.81, for the ultrasound and office visit. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 16, 2022 Ultrasound 86.81 $150 $86.81 
February 16, 2022 Office visit 90.96 $20 $20 
TOTAL:    $106.81 
 
The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies and the 
office visit falls with 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 cost share for ultrasound and office visit provided on February 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hyperbaric chamber therapy provided on 
January 3, 2022 to February 9, 2022. 
 
You asked the Plan to waive the copayment for hyperbaric chamber therapy. You say that you should not be 
charged for an office visit each time you for treatment. The Plan denied your request. The Plan says 
coinsurance 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 $50 
copayment for wound care at an outpatient hospital.  
 
  You have been asked to pay $500 for hyperbaric chamber therapy ($50/visit x 10 = $500). The hyperbaric 
chamber therapy falls 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 hyperbaric chamber therapy provided on January 3, 2022 to February 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided December 17, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you have a condition that causes you to 
become lightheaded, and you did not need to go to the hospital. The Plan denied your request. The Plan says 
this service is not covered when there is no transport. 
 
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 17, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ophthalmological services provided on October 27, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ophthalmological services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 Ophthalmological services provided on October 
27, 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 urgent care visit on January 25, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were not given appropriate 
care so you should not be responsible for this bill. The Plan denied your request. The Plan says coinsurance 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 $40 
copayment for urgent care center visit.  
 
You have been asked to pay $40 copayment for urgent care visit. The 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 to waive the copayment for urgent care 
visit on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  specialist office visit provided on July 28, 
2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you did not previously have 
a copayment for this service in the past 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 Physician specialist services (including surgery second opinion, telehealth, and urgently needed 
services).  
 You have been asked to pay $35 copayment for specialist office visit. The specialist visit falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for  specialist office visit provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient does not come here to your 
laboratory, so he/she is not using out-of-network benefits as his/her participating doctor sends you the 
specimen(s) to process. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan, and they have also determined that these services are not urgent or emergent, nor were they 
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 laboratory services provided on January 25, 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 Domiciliary services provided on November 10, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were 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 Domiciliary services provided on November 10, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided on February 7, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for office visit services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were 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 office visit services provided on February 7, 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 oncology (breast), mRNA, gene expression profiling 
(81519) rendered by the out-of-network (OON) provider on May 28, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service.  Therefore, we decided that the Plan does not have to pay for the oncology (breast), mRNA, gene expression 
profiling (81519) rendered by the out-of-network (OON) provider on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on February 9, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you have had this service done before 
and didn't have a copayment then. 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 $45 
copayment for podiatry services.  
 
You have been asked to pay $45 copayment for office visit. The office visits fall within the Podiatry 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 provided on February 
9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
(90792) rendered by the out-of-network (OON) provider on October 13, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) rendered by the 
out-of-network (OON) provider on October 13, 2021.