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 June 29, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on June 29, 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 the psychotherapy service (90837) provided on March 24, 
2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that you were advised by a plan 
representative that the telephone sessions would be entirely covered. You also say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says the provider in this case is not eligible to 
receive Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue was not enrolled in the Medicare 
program on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy service (90837) provided on March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on April 22, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you would like to appeal this service. The 
Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 22, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on June 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit and related services. We found no exception that would require the Plan to pay for the office visit 
and related services. Therefore, we decided that the Plan does not have to pay for the office visit and related 
services provided on June 20, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for bifocal lenses (V2203) and anti-reflective lens coating 
(V2750) provided on June 28, 2022. 
 You asked the Plan to pay more for bifocal lenses (V2203) and anti-reflective lens coating (V2750). You say 
that you were denied payment for bifocal eyeglass lens and anti-reflective lens coating because the optical 
frame allowance has been exhausted. The Plan denied your request. The Plan says optical frame allowance has 
been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 towards frames and lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $300 other eyewear allowance every 
calendar year that you can use to pay for eyewear to correct vision. The record shows you exhausted this 
benefit on June 28, 2022. Based on this information, we decided that the Plan's rules for coverage of bifocal 
lenses (V2203) and anti-reflective lens coating (V2750) have not been met. Therefore, we decided that the Plan 
does not have to pay more for bifocal lenses (V2203) and anti-reflective lens coating (V2750) provided on June 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on May 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says services performed out-of-network are 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 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 the office visit (99213) provided on May 26, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse a health club membership (S9970). 
 
You asked the Plan to reimburse a health club membership (S9970). You say that this was for membership 
dates in 2022. You also say that you have type two diabetes and needs to exercise. The Plan denied your 
request. The Plan says your submission for your 2021 wellness allowance reimbursement was received after 
March 31, 2022. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when reimbursement requests are received by March 31st of the following year. 
 
 
  The Plans rules for coverage of gym benefits have not been met because health club membership (S9970). The 
record shows that the 2021 wellness allowance reimbursement submission was sent to and received by the Plan 
after March 21, 2022. Therefore, we decided that the Plan does not have to reimburse a health club membership 
(S9970).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 20, 2022, billed with 
codes 81210, 81235, 81275 ,81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
March 20, 2022, billed with codes 81210, 81235, 81275 ,81276, 81292, 81295, 81298, 81301, 81311, 81317, 
81321, 81194 and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit with an out of network 
facility provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit with an out of network facility. You say that 
you know you have a $45 copayment for a specialist, but you got a bill for $89.05 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 $45 
copayment for Physician/Practitioner services, including doctor's office visits. You saw an in-network provider 
in an out of network facility. You are being charged a $45 copayment and a $44.05 facility charge ($45 + 
$44.05 = $89.05). 
 
You have been asked to pay a $89.05 copayment for a specialist visit with an out of network facility. This 
item/service falls 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 visit with an out of network facility 
provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on May 12, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you thought 
this was your yearly routine eye appointment and examination. You also say you feel misled as you did not 
know they would be charging for any additional services than routine. 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 $35 
copayment for a Medicare-covered eye exam.  
 
 
  You have been asked to pay a $35 copayment for a medical eye examination (92014). This item/service falls 
within the Medicare-covered eye exam 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 medical eye examination (92014) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services provided to the enrollee were billed 
accordingly. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 
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 December 21, 2021, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room service provided on 
August 18, 2022. 
 
You asked the Plan to waive the copayment for an emergency room service. You say that you should not pay 
for an emergency room copayment. 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 in-network emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room service. This item/service falls within the 
in-network 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 
emergency room service provided on August 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on May 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 physical therapy provided on May 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA genetic testing (81432, 81433) provided on May 17, 
2022. 
 
You asked the Plan to pay for BRCA genetic testing. You say that this is necessary due to the enrollee's family 
history. The Plan denied your request. The Plan says this was a screening service. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is not reasonable 
and necessary, thus it is non-covered, for the testing of individuals with no personal history of breast, ovarian, 
fallopian tube, primary peritoneal, pancreatic, or prostate cancer. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has a personal history of 
cancer. Based on this information, we decided that Medicare rules for coverage of BRCA genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for BRCA genetic testing (81432, 
81433) provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 9, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like the medical records reviewed 
and the claim to be reprocessed and paid. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 laboratory services provided on March 9, 2022, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on February 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that it would have been impossible to obtain 
authorization as the enrollee provided the incorrect insurance information. You also say that the services were 
medically necessary. The Plan denied your request. The Plan says authorization was not obtained before the 
services were rendered to the enrollee. The Plan also says that the services were nor 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 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 the podiatry services provided on February 3, 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 office visit provided on December 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 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 office visit provided on December 27, 2021, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on April 13, 2021, to May 
04, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says for Medicare-covered services, if the enrollee requires specialized services 
that are not available from a provider in our network, contact their Primary Care Physician (PCP) for 
authorization and coordination of care. Members are entitled to receive services from out-of-network providers 
for emergency or out-of-area urgently needed services. Dialysis services are covered for ESRD members who 
have traveled outside of the plans service area and are not able to access contracted ESRD 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 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 inpatient hospital stay provided on April 13, 2021, 
to May 04, 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 immunization administration provided on June 24, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for immunization administration. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 immunization administration provided on June 24, 
2022, by an out-of-network (OON) provider.