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

 
We decided that the Plan does not have to pay for an office or other outpatient visit and related services 
provided on December 16, 2021, by a provider who has opted out of Medicare. 
 
You asked the Plan to pay for an office or other outpatient visit and related services. You say that the services 
at issue were a necessity for your care. The Plan denied your request. The Plan says rules for payment have not 
been met because the provider at issue has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
or other outpatient visit and related services provided on December 16, 2021, by a provider who has opted out 
of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye exam (92014) provided on January 
11, 2022. 
 
 You asked the Plan to reduce the copayment for the eye exam. You say that an annual wellness exam is 
supposed to be covered, and it was not a specialist visit. You also say that it was not even a doctor that 
provided the service, but their assistant that does the wellness visits. The Plan denied your request. The Plan 
says it was determined you received a medical eye examination on this date of service. 
 
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. You are responsible for a $50 copayment for each Medicare-covered outpatient visit for services to 
diagnose and/or treat a disease or condition of the eye. 
 
We looked at the file and the Plan's rules. The record shows that on this date of service, you received a medical 
eye examination for the diagnosis of Nuclear sclerotic cataract of both eyes. Based on this information, we 
decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the 
Plan does not have to reduce the copayment for the eye exam (92014) provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on December 29, 
2021. 
 You asked the Plan to pay for the provided monitor. You say that the medical records support the level of care. 
The Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 does not indicate that the enrollee performs blood 
glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the continuous glucose monitor provided on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided from March 
24, 2022 to April 14, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are unhappy with your 
benefit for the facility copayment. You say that you were shocked the copayment was $200. 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 $200 
copayment per visit at an in-network hospital outpatient facility and ambulatory surgical centers. Prior 
authorization is required for some services provided by your doctor or other network provider.  
 
You have been asked to pay a total of $800 ($200 x 4 visits = $800). The outpatient 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 outpatient surgery provided from March 24, 2022 to April 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusions on March 5, 2022, and April 2, 
2022. 
 
You asked the Plan to waive the coinsurance for infusions on March 5, 2022, and April 2, 2022. You say that 
you were not aware this would be processed as a Part B medication. The Plan denied your request. The Plan 
says you are responsible to pay a 20% coinsurance for an infusion. 
 
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 Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for infusions on March 5, 2022, and April 2, 2022. An infusion 
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 infusions on March 5, 2022, and April 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 2, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the provided services. You say that medical supply companies were double the 
price. The Plan denied your request. The Plan says the provider is not an authorized Medicare provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The file shows that a walker was received. The provider in this case is not a network provider with the Plan or 
authorized by Medicare. The Plan had network providers available who could have provided the items at issue 
in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the 
Plan to pay for the provided walker. Therefore, we decided that the Plan does not have to pay for the durable 
medical equipment provided on April 2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you need additional transportation to get to 
your treatment 3 times per week. The Plan denied your request. The Plan says additional trips beyond the 
allowed 36 per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on June 8, 2021. 
 
You asked the Plan to pay for the PrismRA test. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the enrollee has a diagnosis of rheumatoid arthritis. The clinical value and 
effectiveness of PrismRA in the setting of rheumatoid arthritis have not been demonstrated. This means the 
PrismRA test at issue in this appeal was requested solely for screening purposes in this case. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
PrismRA test provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection with Nutripharmaceutical blend and electrical 
stimulation therapy provided on October 9, 2020. 
 
You asked the Plan to pay for injection with Nutripharmaceutical blend and electrical stimulation therapy. You 
say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan 
says rules for payment have not been met because the services at issue are experimental/investigational. 
 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 pay for injection with Nutripharmaceutical blend 
and electrical stimulation therapy. Our reviewer says that the services at issue are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the clinical value and effectiveness of 
electrical cell stimulation and the subcutaneous injection of Nutripharmaceutical blend in the setting of chronic 
pain syndrome, paresthesias of skins and diabetic polyneuropathy has not been demonstrated in the peer-
reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection with Nutripharmaceutical blend and electrical stimulation therapy 
have not been met. Therefore, we decided that the Plan does not have to pay for injection with 
Nutripharmaceutical blend and electrical stimulation therapy provided on October 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $55 copayment for mental health services rendered on 
December 1, 2021. 
 
You asked the Plan to waive your $55 copayment for mental health services rendered on December 1, 2021. 
You say that you were told this provider was in-network. The Plan denied your request. The Plan says you are 
responsible to pay a $55 copayment for out-of-network individual or group mental health therapy. 
 
 
 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 $55 
copayment for Outpatient Mental Health Care.  
 
You have been asked to pay a $55 copayment for individual therapy rendered by an out-of-network provider. 
Individual therapy falls within the Outpatient Mental Health 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 your $55 copayment for mental health services rendered on December 1, 2021.  
 
Your complaint about being given incorrect information about the network status of the provider is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $40 more for the single vision lens and deluxe frames. We decided that the 
Plan does not have to pay in full for the single vision lens and deluxe frames.  
 
You asked the Plan to pay in full for the single vision lens and deluxe frames. You say that you were charged 
$69.99 for two pairs of glasses which is under the $100 allowance limit. You also say that you confirmed you 
were within your glasses allowance. The Plan says that this second pair of frames and lenses exceeded the $100 
allowance. 
 
  We decided that the Plan has to pay $40 more for the single vision lens and deluxe frames.  
 
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 up to $100 for non-Medicare covered eyewear. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $56.97 for the first set of glasses, 
and only paid $3.03 for the second set of glasses. These amounts deducted from your $100 eyewear allowance 
leaves you with a total of $40.00 to be used. Based on this information, we decided that the Plan's rules for 
coverage of the single vision lens and deluxe frames have been met. Therefore, we decided that the Plan has to 
pay $40 more for the single vision lens and deluxe frames.  
 
We also decided that the Plan does not have to pay in full for the single vision lens and deluxe frames. 
 
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 up to $100 for non-Medicare covered eyewear. 
 
We looked at the file and the Plan's rules. We have told the Plan to pay an additional $40 for the second set of 
glasses, which has exhausted your $100 allowance. Based on this information, we decided that the Plan's rules 
for coverage of the single vision lens and deluxe frames have not been met. Therefore, we decided that the Plan 
does not have to pay in full for the single vision lens and deluxe frames. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion, lumbar laminectomy and hospital 
inpatient admission for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not meet requirements for surgery. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no recent 
MRI in the last year showing severe spinal stenosis or instability. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion, lumbar laminectomy and hospital inpatient admission for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scans of the 
thorax and abdomen and pelvis provided on September 24, 2021. 
 
You asked the Plan to waive the copayment for the CT scans. You say that you are on a limited income and 
cannot afford the copayment. 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 $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for the CT scans. The CT scans 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 computed tomography (CT) scans of the thorax and abdomen and pelvis provided on 
September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the eye exam (92014) and eye refraction 
(92015) provided on February 22, 2022. 
 
You asked the Plan to waive the deductible for the eye exam (92014) and eye refraction (92015) provided on 
February 22, 2022. You say that the treating provider is in-network, and you were told your insurance would 
cover this visit. The Plan denied your request. The Plan says the cost-share was applied correctly as outlined in 
your 2022 plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot 
be waived. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to non-routine vision services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category of non-
routine vision services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $500 deductible which applies to non-routine vision services. This cost sharing is a contractual obligation that 
had not been met at the time the eye exam (92014) and eye refraction (92015) provided on February 22, 2022. 
was received on February 22, 2022. Therefore, we decided that the Plan does not have to waive the deductible 
for the eye exam (92014) and eye refraction (92015) provided on February 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) and noninvasive ear 
or pulse oximetry for oxygen saturation, single determination (94760) provided June 15, 2021. 
 
You asked the Plan to pay for the emergency services. You say that you are appealing the Medicare approval 
letter and medical records so please review and reconsider the claim. The Plan denied your request. The Plan 
says essential data elements to process claim are missing and/or invalid per contractual or CMS guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program on the date of service. Independent Freestanding Emergency Department services are covered as a 
hospital only upon CMS approval. Date of service June 15, 2021 is prior to the CMS approval effective date of 
August 03, 2021, therefore the provider was not Medicare eligible for the date of service. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99283) and noninvasive ear or 
pulse oximetry for oxygen saturation, single determination (94760) provided June 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the home health aide services are reasonable and necessary to 
the treatment of your illness or injury by the skilled professional staff as defined by Medicare criteria. Provided 
records do not document that any skilled home health nursing or therapy services are being provided at this 
time. As no skilled home health nursing or therapy services are being provided at this time, home health aide 
services are not a Medicare covered benefit. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.