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

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on October 5, 
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 domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the treatment of a finger fracture 
(26720) rendered by the out-of-network (OON) provider on October 8, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99203) and the treatment of a finger fracture (26720) rendered by 
the out-of-network (OON) provider on October 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound, limited, of a joint or other 
non-vascular extremity structure(s) (76882) provided on December 9, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $85 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free standing facility.  
 You have been asked to pay $55.62 for the Medicare-covered radiological diagnostic service provided. This is 
the Plans allowed amount for this service, which is less than the applicable copayment. 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 ultrasound, limited, of a joint or other non-vascular extremity 
structure(s) (76882) provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Therapies provided on November 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Therapies. 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 Outpatient Therapies provided on November 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative evaluation 
of coronary calcium (75571). 
 
You asked the Plan to pre-approve computed tomography (CT) with quantitative evaluation of coronary 
calcium.. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested service is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that quantitative calcium scoring is not a covered service and will be denied as not medically necessary. 
 
Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative 
evaluation of coronary calcium (75571).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic endoscopy provided on 
January 13, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic endoscopy. You say that you believed the 
insurance would cover this procedure. You also say that you received a bill for $270. 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 $150 
copayment for outpatient diagnostic testing.  
 
The Plan confirmed you had a previous balance of $125 which does not involve the endoscopy received on 
January 13, 2022. You have been asked to pay a $145, which is less than the $150 copayment for a diagnostic endoscopy. A diagnostic endoscopy 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 copayment for a diagnostic endoscopy 
provided on January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December 
14, 2021 to December 16, 2021 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel you should not 
be charged for a semi-private room. The Plan denied your request. The Plan says you have been charged the 
correct copayment 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 $365 
copayment for each day for days 1-5.  
 
 
 You have been asked to pay a total of $730 for the inpatient hospital stay ($365/day x 2 = $730). The inpatient 
hospital 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 hospital stay from December 14, 2021 to December 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
24, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the provider told you there 
would be no copayment for a COVID test. The Plan denied your request. The Plan says the provider submitted 
a claim for the COVID test, and it was covered and paid in full. The proper copayment was charged for the 
urgent care visit. 
 
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 each covered office visit to other providers for urgently needed services.  
 You have been asked to pay a $40 copayment for the 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 an urgent 
care visit provided on December 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 18, 2021, to January 4, 2022.  
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that  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 $100 
copayment per day for days 1-7 for an inpatient hospital stay for Inland Empire, Kern County Basic, Kern 
County Enhanced, or Los Angeles and Orange counties plan members. The contract also says that there is a $0 
copayment for additional days after day 7. You have been asked to pay a total of $700, which is a $100 copayment per day for days 1-7 for an inpatient 
hospital stay ($100 copayment x 7 days = $700). There is no charge after day 7. An inpatient hospital 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 hospital stay provided from December 18, 2021, to January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the anesthetic agent injection provided on 
January 17, 2022. 
 
You asked the Plan to waive the copayment for the anesthetic agent injection. You say that when you had 
coverage with a different plan this was covered so it should be covered now. 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). You have been asked to pay $40 copayment for anesthetic agent 
injection. Anesthetic agent injection 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 anesthetic agent injection 
provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the 
out-of-network (OON) provider on February 25, 2022. 
 
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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) 
provider on February 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a collagenase injection provided on 
January 20, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not aware that the Plan 
would only cover 80% of the cost. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs, including injectable drugs.  
 
You have been asked to pay $1,018.80, which is 20% of the allowed amount for the injection ($5,094.00 
allowed amount x 20% coinsurance = $1,018.80). The injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for a collagenase injection provided 
on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
29, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the blood work was part of 
your annual physical and you say you believe it should not have a copayment. The Plan denied your request. 
The Plan says you have been charged the correct copayment 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 $10 
copayment per day for other Medicare-covered laboratory tests that are not FIT tests.  
 
 
 You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for laboratory services provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on February 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the enrollee was not aware they had to switch 
providers due to enrolling into the Plan. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a telehealth visit provided on February 8, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for an ECG. You say that you have had electrocardiograms in the 
past and was never billed extra for them. 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 $30 
copayment for outpatient diagnostic tests, including ECGs.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $14.45, which is less than the $30 copayment for an ECG. An ECG 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 copayment for an electrocardiogram (ECG) provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve acupuncture visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve twelve acupuncture visits to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
twelve acupuncture visits to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must either have a history of osteoporosis-related fracture, or 
the enrollee has tried and failed, or has a contraindication to zoledronic acid. 
 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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the Plan requires the enrollee to either 
have a history of osteoporosis-related fracture, or the enrollee must have tried and failed, or has a 
contraindication to zoledronic acid before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a temporary implantable nitinol device 
(iTIND) with cystourethroscopy. 
 
You asked the Plan to pre-approve insertion of an iTIND with cystourethroscopy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an iTIND with 
cystourethroscopy. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the services (iTIND) are not medically reasonable and 
necessary. Further studies are needed to evaluate the durability of TIND outcomes over a longer follow-up, to 
better define the indications of this approach, and to demonstrate the advantages of second-generation device 
over the first device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an iTIND with cystourethroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a temporary implantable nitinol device (iTIND) 
with cystourethroscopy.