Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on October 7, 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 subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on October 7, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Evenity. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial branch block (MBB) injection. 
 
You asked the Plan to pre-approve a medial branch block (MBB) injection. The Plan denied your request. The 
Plan says he MBB injection does not meet the Medicare LCD L38803 coverage criteria. The Plan follows Medicare rules.  
 
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 a medial branch block (MBB) injection. 
Our reviewer says that a medial branch block (MBB) injection is not medically reasonable or necessary. Our 
physician reviewer found that the enrollee has clearly demonstrated foraminal stenosis, which medial branch 
blocks will not address, and which is the probable pain generator. The request does not meet the criteria of the 
LCD. The request is 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 a medial branch block (MBB) injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a medial branch block (MBB) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the alginate dressing (A6197), the non-
waterproof tape (A4450), and the waterproof tape (A4452) provided on November 24, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the items 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 of the Medicare-allowed fee, up to $250, for each Medicare-covered item per date of service for 
prosthetic devices and related supplies.  
 You have been asked to pay $50.50 (Plan allowed amount of $252.48 x 20% coinsurance) for the wound care 
supplies provided. 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 the alginate dressing (A6197), 
the non-waterproof tape (A4450), and the waterproof tape (A4452) provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital visit provided on November 17, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital visit. You say that the enrollee was referred. The Plan 
denied your request. The Plan says the services were provided out-of-network and the ordering physician was 
also out-of-network with the Plan. 
 
 
 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 outpatient hospital visit provided on November 
17, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ground non-emergent ambulance transport 
(A0428, A0425, A0999, A0398, A0422) provided on July 28, 2021. 
 
You asked the Plan to waive the copayment for ground non-emergent ambulance transport. You say that the 
hospital was aware of all these issues due to the coronavirus (COVID-19), yet they did not include the code. 
You also say that you are appealing to the Plan for the adjustment to remove the copayment due to COVID-19. 
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 $265 
copayment per date of service regardless of the number of trips ground non-emergency ambulance for ground 
non-emergency ambulance.   
You have been asked to pay a $265 copayment for ground non-emergent ambulance transport. Ground non-
emergent ambulance transport falls within the ambulance 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 ground non-emergent ambulance transport (A0428, A0425, A0999, A0398, A0422) 
provided on July 28, 2021.  
 
Your complaint about the provider potentially using the incorrect diagnosis codes 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation simulation and treatment 
planning services provided on October 19, 2021, and October 27, 2021. 
 
You asked the Plan to waive the copayments for the radiation simulation and treatment planning services. You 
say that you never went to the providers office to receive this treatment. The Plan denied your request. The 
Plan says the provider confirmed that the service was provided on both dates and the enrollee is not in the 
office when treatment planning takes place. Therefore, the proper copayments were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for per day, per provider, for Medicare-covered, radiation therapy services. The copayment amount 
for both dates of service was $80 ($40 copayment per date x 2 days). You have been asked to pay a $80 copayment for the radiation simulation and treatment planning services. The 
radiation simulation and treatment planning services 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 copayments for radiation 
simulation and treatment planning services provided on October 19, 2021, and October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal allograft transplant (20930). 
 
You asked the Plan to pre-approve the spinal allograft transplant. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 spinal allograft transplant. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found BMP allograft is experimental in posterior spinal surgery. It is not FDA 
approved for usage in the posterior spine. 
 
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 spinal allograft transplant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal allograft transplant (20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from 
August 21, 2021, to August 24, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you are on a fixed 
income and the coinsurance is too high. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for each inpatient stay.  
 
You have been asked to pay $567.48, which is 10% of the allowed amount for the inpatient hospital services 
$5,674.80 allowed amount x 10% coinsurance = $567.48). The inpatient hospital services fall 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 coinsurance for inpatient 
hospital services provided from August 21, 2021, to August 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a psychiatric diagnostic evaluation 
provided on September 15, 2021. 
 
You asked the Plan to waive the coinsurance for a psychiatric diagnostic evaluation. You say that this claim is 
not yours. You also say that you were put in the psychiatric ward because they were trying to get you to sign 
documents. 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 35% 
coinsurance for out of network mental health services at an outpatient hospital.  
 
 The medical records show you received a psychiatric diagnostic evaluation on September 15, 2021. You have 
been asked to pay $63.03, which is 35% of the allowed amount for a psychiatric diagnostic evaluation ($180.08 
allowed amount x 35% coinsurance = $63.03). A psychiatric diagnostic evaluation 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 a psychiatric 
diagnostic evaluation provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on November 1, 2021 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says with limited 
exceptions, members must use network providers to get medical care and services. The only exceptions are 
emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and 
cases in which the Plan authorizes use of out-of-network providers. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient services provided on November 1, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on December 21, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was medical vision check (Type 2 Diabetes, Age-related nuclear cataract, 
bilateral). 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on September 27, 
2021. 
 
You asked the Plan to pay for an X-ray of the chest. You say that the claim denial as a duplicate is an error. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an X-ray of the chest have not been met. Specifically, the Plan has documented that the claim at 
issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does 
not have to pay for an X-ray of the chest (71045) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Office Visit provided on May 10, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an Office Visit. You say that you are seeking a review of the denial. The Plan 
denied your request. The Plan says there is no necessity for an out-of-network provider, such as an urgent or 
emergency situation has been documented. 
 
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 an Office Visit provided on May 10, 2021 by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient biopsy provided on October 
15, 2021. 
 
You asked the Plan to waive the copayment for an outpatient biopsy. You say that you were told the day prior 
to your procedure that there would be no copayment. The Plan denied your request. The Plan says there is no 
documentation that anyone contacted them prior to the procedure to confirm the benefit information and the 
proper copayment was applied for this procedure. 
 
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 $175 
copayment for each Medicare covered visit at a hospital-affiliated outpatient hospital facility or ambulatory 
surgical center.  
 
  You have been asked to pay a $175 copayment for an outpatient biopsy. An outpatient biopsy 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 an 
outpatient biopsy provided on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on November 1, 2021. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you would like for the bill to be paid. 
The Plan denied your request. The Plan says the claim processed correctly, and the proper copayment was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for each covered surgery or observation room service in an outpatient hospital.  
 
  You have been asked to pay a $295 copayment for a 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 biopsy provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on August 12, 2021. 
 
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says that the Plan confirmed 
that this service (Progressive lens) was already received previously on May 22, 2020. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. 
 
 We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on 
May 22, 2020, and you have exhausted the eyewear benefit. Therefore, we decided that the Plan does not have 
to pay for eyeglasses provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient domiciliary, rest home, or custodial care visit 
provided on November 15, 2021. 
 
You asked the Plan to pay for a patient domiciliary, rest home, or custodial care visit. The Plan denied your 
request. The Plan says authorization was not obtained prior to the services being rendered and the provider is 
not participating with the member's plan and the services were not urgent or emergent in nature. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a patient domiciliary, rest home, or custodial care visit provided 
on November 15, 2021.