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

 
We decided that the Plan does not have to pay for the office visit and related services received from February 
15, 2022 to March 16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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 the office visit and related services received from 
February 15, 2022 to March 16, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on February 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the Plan ought not to penalize the provider for 
the facility staff's failure to obtain authorization. The Plan denied your request. The Plan says rules for payment 
for OON care 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 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 nursing facility care (99309) provided on February 
15, 2022, by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of Antineoplastic chemotherapy induced pancytopenia. The Plan requires a trial of Retacrit before 
they will approve the requested drug. In this case, the record does not contain documentation of trail and failure 
of Retacrit. In addition, the documentation in the case file does not support that Retacrit would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and imaging provided on April 25, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 the eye exam and imaging provided on April 25, 
2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2022, billed with 
codes 87541 and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid in full. The Plan 
denied your request. The Plan says the panel should be billed with one single panel code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 19, 2022, billed with codes 87541 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 16, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you did not see that doctor that day 
and therefore the claim is not correct. The Plan denied your request. The Plan says the cost sharing you are 
being charged 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 a $10 
copayment for each primary care doctor office visit for Medicare-covered services. Covered services include 
medically necessary medical care or surgery services furnished in a physicians office, certified ambulatory 
surgical center, hospital outpatient department, or any other location. 
 
 
 
 
 You have been asked to pay a $10 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for office visit on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter COVID-19 test purchased on March 18, 
2022. 
 
You asked the Plan to pay for an over-the-counter COVID-19 test. You say that you needed this to travel. The 
Plan denied your request. The Plan says this was purchased before the start of the benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has started a new initiative on April 4, 
2022, that will cover up to eight over-the-counter COVID-19 tests each calendar month, at no cost. 
 
We looked at the file and Medicare rules. The test at issue was purchased before the start of the Medicare 
benefit on April 4, 2022. The record does not indicate the Plan offered an additional benefit for COVID-19 
tests before this date. Based on this information, we decided that Medicare rules for coverage of an over-the-
counter COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for an 
over-the-counter COVID-19 test purchased on March 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a denosumab injection (J0897) provided 
on February 10, 2022. 
 
You asked the Plan to waive the cost-sharing for the denosumab injection. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for the denosumab injection (allowed is $1,272.30 x 20% = 
$254.46). the denosumab 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 cost-sharing for a denosumab injection (J0897) provided on February 10, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on March 23, 
2022 to May 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you do not want to see another therapist. 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 rules say that a Licensed Mental Health Counselor is not 
eligible to participate in Medicare. 
 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. 
Furthermore, the services were performed by a licensed mental health counselor and this provider type is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the outpatient mental health 
services provided on March 23, 2022 to May 11, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health stay from January 
27, 2022, to February 3, 2022. 
 
You asked the Plan to waive the copayment for inpatient mental health stay. You say that this has been a 
financial hardship for your family and any help would be appreciated. The Plan denied your request. The Plan 
says the copayment 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 a $298 
copayment for inpatient mental health ($298 x 5 = $1490).  
 
You have been asked to pay a $1490 copayment for inpatient mental health stay. Inpatient mental health stay 
falls within the inpatient mental health 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 
inpatient mental health stay from January 27, 2022, to February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
20, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) provided on 
April 14, 2022. 
 
You asked the Plan to waive the copayment for specialist services. You say that you are not happy with the 
copayment because the appointment only lasted four minutes. The Plan denied your request. The Plan says the 
cost-share was applied in accordance with your contract with the Plan. 
 
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 specialist visits.  
 
You have been asked to pay a $50 copayment for specialist services. Specialist office visits fall within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan.  
 
 
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a specialist office visit (99204) provided on 
April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 10, 2020. 
 
You asked the Plan to pay for the medical services. You say that you did not receive notice of this member's 
benefit determination and that's why the claim was submitted untimely. The Plan denied your request. The Plan 
says you did not timely file your claim.  There is no evidence of the claim being submitted prior to February 9, 
2022. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
medical services was not filed until February 9, 2022. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for medical services provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on March 4, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you should not have a copayment 
this high. The Plan denied your request. The Plan says the copayment 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 a $335 
copayment for outpatient hospital surgical services.  
 
You have been asked to pay the allowed amount of $293.80 which is less than the $335 copayment for an 
injection. An injection falls within the Outpatient Hospital Surgical 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 injection provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate dressings provided on June 7, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 the alginate dressings provided on June 7, 2022 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5050) provided on September 20, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you feel you were misled, as you were told to use 
this hearing aid company by the Plan. The Plan denied your request. The Plan says the hearing aid brand you 
purchased is not on the hearing aid formulary under the Plan's hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use Plan approved hearing aids to receive hearing aid benefits.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aids (V5050) provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
7, 2022, to April 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were only under 
observation and not inpatient. 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 $290 per 
day for days 1-4 and $0 per day for days 5-90 for each inpatient admission.  
 
The file shows that the inpatient order was made and you were in the hospital from April 7, 2022, to April 10, 
2022. Since there is no copayment for the discharge date, you have been asked to pay $290 per day for days 1-3 
of inpatient care. The total for your stay is $870 ($290 copayment x 3 days = $870). The inpatient care 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 
inpatient hospital care provided from April 7, 2022, to April 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the virtual care services provided on December 7, 2021, 
December 15, 2021, and December 21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the virtual care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 the virtual care services provided on December 7, 
2021, December 15, 2021, and December 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on April 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON mental health services. You say that this should be paid. The Plan 
denied your request. The Plan says this service was provided OON without authorization. There is no 
indication this was an emergency situation. 
 
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 the mental health services provided on April 19, 
2022, by an out-of-network (OON) provider.