Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy from December 10, 2021, 
to January 11, 2022. 
 
You asked the Plan to waive the copayments for physical therapy from December 10, 2021, to January 11, 
2022. You say that the copayments are exorbitant and that you are on a fixed income and cannot afford it. The 
Plan denied your request. The Plan the cost share has was applied 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 for the 2021 and 2022 
Plan years, you must pay a $40 copayment for Outpatient Rehabilitation Services.  
 You have been asked to pay a $103.11 copayment for physical therapy services rendered from December 10, 
2021, to January 11, 2022. Physical therapy falls within the Outpatient Rehabilitation Services benefit 
category. Your contract with the Plan clearly states you must pay $40 for each physical therapy visit. However, 
for services rendered on January 4, 2022, you have only been asked to pay $29.54 which is less than the 
copayment amount. For services rendered on January 11, 2022, you have only been asked to pay $33.57, which 
is less than the copayment 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 copayments for physical therapy 
from December 10, 2021, to January 11, 2022.  
 
Date of Service Amount Billed Amount Allowed Amount Paid Copayment 
12/10/2021 $554 $113.67 $73.67 $40 
1/4/2022 $199 $29.54 $0 $29.54 
1/11/2022 $199 $33.57 $0 $33. 57 
Total $952 $176.78 $73.67 $103.11
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025), photochromatic tint (V2744), 
anti-reflective coating (V2750), and progressive lens (V2781) provided on March 17, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that you do not have almost $600 to pay for these glasses. 
The Plan denied your request. The Plan says you received these services from an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a Plan-approved optical provider. 
 
 
 
 
 We looked at the file and the Plan's rules. These glasses were rendered by a provider who is not in the Plan's 
network. Based on this information, we decided that the Plan's rules for coverage of the glasses have not been 
met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025), photochromatic 
tint (V2744), anti-reflective coating (V2750), and progressive lens (V2781) provided on March 17, 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 cost for dermatology services provided on November 24, 
2021. 
 
You asked the Plan to waive the cost for dermatology services. You say that you cannot afford this coinsurance 
amount. The Plan denied your request. The Plan says the cost share applied was 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 20% 
coinsurance for each Medicare-covered medical supply from an in-network provider and a $35 copayment for 
services obtained from an in-network specialist. 
  You have been asked to pay a total of $852.14 for the dermatology services. 
 
Service Allowed Amount Standard Cost Member Liability 
Medical Supplies $4,085.69 20% $817.14 
Skin Graft $137 $35 $35 
TOTAL:   $852.14 
 
The medical supplies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The skin graft 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 cost for dermatology services provided on 
November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on January 22, 2021, 
and February 5, 2021. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you thought this would be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $300 
copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility. 
 
You have been asked to pay a total of $600 ($300 x 2 visits) copayment for eye surgery. Eye surgery 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 waive the copayment for eye surgery provided 
on January 22, 2021, and February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 17, 2022 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this ambulance transport was medically necessary, and the enrollee could not be transported with any other 
means of transportation. The Plan denied your request. The Plan says prior approval was not obtained for the 
non-emergent ambulance 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on January 17, 2022 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
You asked the Plan to pre-approve Ziextenzo. The Plan denied your request. The Plan says the enrollee has not 
tried two of Neulasta, Fulphila, and Udenyca. 
 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 Ziextenzo. Our physician reviewer 
found that Ziextenzo was requested to treat chemotherapy-related neutropenia. The Plan requires a trial of two 
of Neulasta, Fulphila, and Udenyca before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs would likely be less effective 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 Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a prostate biopsy performed on January 11, 
2022. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you had this procedure done before 
and it was covered. 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 $375 
copayment for each outpatient surgery at an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay a $375 copayment for the biopsy. The biopsy 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 waive the copayment for a prostate biopsy performed on 
January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 25, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not think you 
should be charged the $25 since it was a follow-up visit to your rehabilitation. The Plan denied your request. 
The Plan says you were 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 $25 
copayment for specialty care physician.  
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for a specialist office visit. A specialist office 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 a specialist office visit provided on February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 7, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you dont agree with the 
charge. 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 $260 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 
 
 
You have been asked to pay $260 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery and Other Medical 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 waive the copayment for outpatient surgery 
provided on February 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided from January 
10, 2022, to January 16, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not enrolled in hospice on the 
dates of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 8, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99233) provided from January 10, 2022, to January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have waive the coinsurance for laboratory tests on February 16, 2022. 
 
You asked the Plan waive the coinsurance for laboratory tests on February 16, 2022. You say that you only 
expected your cost share to be about $15. The Plan denied your request. The Plan says you are responsible to 
pay $118.18 for in-network laboratory tests on February 16, 2022. 
 
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 20% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services And Supplies.  
 
The enrollee has been asked to pay a 20% coinsurance for laboratory tests. Laboratory tests fall within the 
Outpatient Diagnostic Tests and Therapeutic Services And Supplies benefit category. The Plans allowance for 
these tests was $590.88; $590.88 x 20% = $118.18. 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 waive the 
coinsurance for laboratory tests on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services (97026) provided from April 5, 
2021, through April 12, 2021. 
 
You asked the Plan to pay for the infrared therapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this service is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy services will not be covered. 
Based on this information, we decided that Medicare rules for coverage of the infrared therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the infrared therapy services 
(97026) provided from April 5, 2021, through April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84479, 84436, 80061, 83036) provided 
on February 22, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 (84479, 84436, 80061, 83036) 
provided on February 22, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for observation services on February 22, 2022.  
 
You asked the Plan to waive the copayment for observation services on February 22, 2022. You say that in the 
past, this has been covered. The Plan denied your request. The Plan says the copayment has been applied 
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 $235 
copayment for Outpatient Hospital Observation.  
 
You have been asked to pay a $117.53 copayment for a hospital observation services. Hospital observation 
services fall within the Outpatient Hospital Observation benefit category. Your contract with the Plan clearly 
says that you must pay a $235 copayment for observation services. However, you have only been asked to pay 
$117.53, which is less than the copayment 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 
observation services on February 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kit purchased on February 9, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kit. You say that when you contacted the Plan prior 
to purchasing the test kit, you were told the test kit would be covered under your Wellness Wallet. The Plan 
denied your request. The Plan says this service is not covered. The Plan also says when you contacted the Plan 
on January 31, 2022, you were advised that home COVID-19 test kits are not covered under your Wellness 
Wallet benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for over-the-counter (OTC) 
items and the at-home COVID-19 test kit is an OTC item. However, the Plan offers a Wellness Wallet benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a Wellness Wallet benefit in excess of Medicare coverage, the requested items or 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the at-home COVID-19 test kit purchased on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-discountable items and warranties (V2797) provided 
on March 10, 2022. 
 You asked the Plan to pay for the non-discountable items and warranties. You say that you disagree with the 
Plan's denial and feel payment should be made for your benefit requirements. The Plan denied your request. 
The Plan says this service is not covered by your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the services listed in the 2022 Evidence of Coverage. 
 
We looked at the file and the Plan's rules. Non-discountable items and warranties (V2797) is not listed as a 
covered vision benefit. Based on this information, we decided that the Plan's rules for coverage of the non-
discountable items and warranties have not been met. Therefore, we decided that the Plan does not have to pay 
for the non-discountable items and warranties (V2797) provided on March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint arthrodesis procedure. 
 
You asked the Plan to pre-approve the requested services. You say that coverage criteria have not been met. 
The Plan denied your request. The Plan says you are in severe pain. 
 
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 the requested services. Our physician 
reviewer found that the records show that you have both hip and back arthritis. It is unclear if the sacroiliac (SI) 
joint is the problem. There is no SI joint instability, fracture, or lesion. Therefore, the requested services are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint arthrodesis procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autogenous connective tissue graft procedure (D4273), 
osseous surgery (D4260), and removal of lateral exostosis (D7471) provided on December 13, 2021 by a 
Medicare opt out provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware this treating provider was 
not a participating provider. The Plan denied your request. The Plan says you received these services from a 
provider who chose not to receive Medicare funds. 
 
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, the requested items or services are not 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the autogenous connective tissue graft procedure (D4273), osseous surgery 
(D4260), and removal of lateral exostosis (D7471) provided on December 13, 2021 by a Medicare opt out 
provider.