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

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
(93793) provided on December 2, 2021, and December 29, 2021. 
 
You asked the Plan to waive the copayment for the PCP office visits. You say that there should be no 
copayment for lab work and that you are being billed $9.60. You also say you were told it may be a code issue. 
The Plan denied your request. The Plan says you have been charged the correct cost share amount. The Plan 
also says that these claims were reprocessed, and the cost share was reduced to a $5 copayment for each PCP 
visit on December 2, 2021, and December 29, 2021 
 
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 $5 
copayment for an in-network PCP office visit.  
 The record shows that code 93793 is considered a physician service. You have been asked to pay a $5 
copayment for each PCP office visit on December 2, 2021, and December 29, 2021. A PCP 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 primary care physician (PCP) office visit (93793) provided on 
December 2, 2021, and December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 25, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the leg arteries provided 
on January 13, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that should not have to pay $50 for a 
test that you did not need due to inaccurate results from a broken machine being sent to your primary doctor. 
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 $50 
copayment for diagnostic radiology services, including ultrasounds.  
 
The record shows you had an ultrasound on January 13, 2022, and cost sharing applies. You have been asked to 
pay a $50 copayment for an ultrasound. An ultrasound 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 ultrasound of the leg arteries provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out-of-network (OON) anesthesia services 
provided on December 16, 2021. 
 
You asked the Plan to waive the deductible for the OON anesthesia services. You say that you did not know the 
provider was out of network. The Plan denied your request. The Plan says the correct amount was applied to 
your deductible. 
 
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 $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1,000 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the anesthesia services were received on December 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for out-of-
network (OON) anesthesia services provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from October 4, 2021, 
through December 10, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided from 
October 4, 2021, through December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says there is no exception that would allow the plan to approve additional rides to non-PCP 
locations. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for an office visit provided on November 30, 
2021. 
 
You asked the Plan to reduce the deductible for an office visit. You say that you were not told that the provider 
was out-of-network. You also say that you paid your $5 copayment at the time of the appointment. 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. Your 
contract with the Plan says that there is a $350 deductible which applies to an out-of-network office visit.  
 
The item or service you asked the Plan to reduce the deductible for falls within the Physician/Practitioner 
Services, Including Doctors Office Visit benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $350 deductible which applies to an out-of-network office visit. This 
cost sharing is a contractual obligation that had not been met at the time an office visit was received on 
November 30, 2021. Therefore, we decided that the Plan does not have to reduce the deductible for an office 
visit provided on November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on January 27, 
2022. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you were referred to the physician 
for medication management. The Plan denied your request. The Plan says you have been charged the correct 
coinsurance 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 20% 
coinsurance for out of network outpatient mental health care.  
 
You have been asked to pay $35.82, which is 20% of the allowed amount for the office visit ($179.12 x 20% = 
38.52). The office visit 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 the coinsurance for an office visit provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on December 11, 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 office visit (99215) rendered by the out-of-network (OON) provider on  
December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes (L3230). 
 
You asked the Plan to pre-approve orthopedic shoes. You say that you cannot walk without orthopedic shoes 
due to nerve pain. The Plan denied your request. The Plan says orthopedic shoes are not covered for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoes (L3230).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecfidera 240mg tablets. 
 
You asked the Plan to pre-approve Tecfidera. You say that Tecfidera is medically necessary. The Plan denied 
your request. The Plan says Tecfidera is not eligible for coverage under the Part B medical 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 Tecfidera 240mg tablets.  
 
Benefits for Tecfidera 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8mg. 
 
You asked the Plan to pre-approve Ondansetron. You say that Ondansetron is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Ondansetron 8mg.  
 
Benefits for Ondansetron 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 waive the coinsurance for an injection of hyaluronan provided on 
December 17, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you never had to pay that much 
under your previous insurance. The Plan denied your request. The Plan says the coinsurance 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 you must pay 20% 
coinsurance for Medicare Part B Drugs. The allowed amount totaled $1,154.17 resulting in a total of $230.83. 
 
 
  You have been asked to pay a total of $230.83 for Part B Drugs. Part B drugs fall 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 an injection of 
hyaluronan provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on June 29, 2021. 
 
You asked the Plan to pay for an opioid treatment program. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 
service 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 an opioid treatment program provided on June 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fiberscopic laryngoscopy provided on 
October 14, 2021. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you were only told about the $45 
copayment, and nothing was said to you about a $350 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 $350 
copayment for outpatient procedures and services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$350 copayment for a laryngoscopy. A laryngoscopy 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 a fiberscopic laryngoscopy provided on 
October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on January 20, 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 office visit (99214) rendered by the out-of-network (OON) provider on January 20, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bupivacaine liposome (Exparel). 
 
You asked the Plan to pre-approve bupivacaine liposome (Exparel). You say that the requested bupivacaine 
liposome (Exparel) is medically necessary. The Plan denied your request. The Plan says the requested 
bupivacaine liposome (Exparel) is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 bupivacaine liposome (Exparel). Our 
reviewer says that the requested bupivacaine liposome (Exparel) is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of pain from Spondylosis without 
myelopathy or radiculopathy, cervical region.  The record does not indicate that the requested drug is being 
used in a postoperative setting. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bupivacaine liposome (Exparel) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bupivacaine liposome (Exparel).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, harness and electronic 
connection between wheelchair controller and 2 or more power seating system motors. 
 
You asked the Plan to pre-approve expandable controller, harness and electronic connection between 
wheelchair controller and 2 or more power seating system motors. 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 follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 expandable controller, harness and 
electronic connection between wheelchair controller and 2 or more power seating system motors. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found clinical documentation does 
not report any limitations by enrollee's left upper extremity thus E2377 (expandable controller), E2313 
(expandable controller harness), E2311 (expandable controller with electronic connections to power chair 
functions) are not medically necessary as each function has its own operation available for the enrollee to use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness and electronic connection between wheelchair 
controller and 2 or more power seating system motors have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller, harness and electronic connection between wheelchair 
controller and 2 or more power seating system motors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says this device is primarily for use outside the home, and is therefore 
non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0800).