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

 
We decided that the Plan does not have to pay for office visit provided on August 27, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2), sales tax 
(S9999), and the unlisted special service, procedure, or report (99199) purchased from the out-of-network 
(OON) provider on September 13, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract says that hearing aids are covered 
only when purchased from the Plans select hearing aid provider.  However, the hearing aids in this case were purchased from an out-of-network provider. Additionally, as the 
hearing aids purchased from an out-of-network provider are not covered, any associated charges would also not 
be covered.  Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5298 x 2), sales tax (S9999), and the unlisted special service, procedure, or report (99199) purchased from 
the out-of-network (OON) provider on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on November 07, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
care provided on November 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on February 22, 2022, to October 12, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME $5,427.45. 
You are being asked to pay $1,085.49 ($5,427.45 x 20% =$1,085.49). This item/service falls within the durable 
medical equipment (DME) 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 durable 
medical equipment (DME) provided on February 22, 2022, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on December 21, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that COVID-19 testing is free so you 
should not have to pay this bill. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for urgently needed services. 
 
You have been asked to pay a $25 copayment for urgent care visit. This item/service falls within the urgently 
needed 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 urgent care visit provided 
on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on October 18, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
waited too long for treatment, and that you were disappointed with your treatment. You left after this. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency 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 
an in-network emergency room (ER) visit provided on October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
May 25, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram (ECG). You say that you disagree with 
the copaymet. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests/Non-radiological diagnostic services. 
 
You have been asked to pay a $20 copayment for an electrocardiogram (ECG). This item/service falls within 
the outpatient diagnostic tests/Non-radiological diagnostic 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 electrocardiogram (ECG) provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power mobility device provided on August 05, 2022. 
 
You asked the Plan to pay for power mobility device. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for power mobility device 
provided on August 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
12, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you have not had to pay 
this in the past. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialty care physician. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
specialty care physician benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist 
office visit provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab testing on August 17, 2022. 
 
You asked the Plan to waive the deductible for lab testing. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
lab testing was received on August 17, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for lab testing on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A nerve procedure that affects nerves and use of a 
device called Reactiv8. 
 
You asked the Plan to pre-approve Reactiv8. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that electrical nerve stimulators are only covered for 
certain indications. 
 
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 Reactiv8. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee was being treated for muscle wasting and atrophy not elsewhere 
classified of the back lumbosacral; vertebrogenic low back pain. The enrollee presented still in pain since 
having the basivertebral nerve placement and bilateral L4-5 and L5-S1 radiofrequency ablation. The enrollee 
has low back pain into the right hip and glute area is where it is most painful. The pain at worst is seven out of 
10, at least is zero out of 10, and on average four out of 10. The exam reveals pain over the lumbar 
intervertebral spaces on palpation. Anterior flexion causes pain. There is a positive posterior instability test. 
Strength, sensation, and reflexes are intact. However, detailed documentation is not evident regarding 
multifidus muscle dysfunction. This is noted on exam; however, it is not corroborated by the imaging or other 
objective findings. Moreover, the documentation does not corroborate her pain is intractable, as she notes on 
average her pain is four out of 10. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested device in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested 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 Reactiv8 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve A nerve procedure that affects nerves and use of a device called Reactiv8.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copaymet. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service 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 ambulance services 
provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on September 21, 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 this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on September 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on November 09, 
2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for ambulance service. 
 
You have been asked to pay a $350 copayment for ambulance. This item/service falls within the ambulance 
service 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 ambulance provided on 
November 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management visit provided on October 05, 2022. 
 
You asked the Plan to pay for a pain management visit. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pain management visit 
provided on October 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic otolaryngology visit provided on October 05, 
2022. 
 
You asked the Plan to pay for a therapeutic otolaryngology visit. You say that this should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a therapeutic 
otolaryngology visit provided on October 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 25, 2021. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 25, 2021.