Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing test rendered on 
August 30, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic hearing test. You say that you were told that this 
was a covered service. The Plan denied your request. The Plan says the copayment applied 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 
copay for diagnostic procedures and tests.  
 
 
  You have been asked to pay a $10 copay for the hearing test, which is less than the EOCs $35 copayment for 
Medicare-covered diagnostic hearing exams. The diagnostic hearing test falls within the Outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the diagnostic hearing test rendered on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99334) rendered by the out-of-network (OON) provider on October 14, 
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 domiciliary or rest home visit for the evaluation and management of an established 
patient (99334) rendered by the out-of-network (OON) provider on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (E1007, E2361, E1028, 
E2300, E2620, E1012, E0953, E2377, E2311, E2313, E2622, E0955, E1028, E1028). 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that the power wheelchair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair (E1007, E2361, E1028, E2300, E2620, E1012, E0953, E2377, E2311, E2313, 
E2622, E0955, E1028, E1028).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay the $500 benefit towards the hearing aids (V5261) provided on October 28, 
2021. 
 
You asked the Plan to pay the $500 benefit towards the hearing aids. You say that you would like 
reconsideration because you would like the Plan to pay their share of the hearing aid benefit. The Plan denied 
your request. The Plan says that authorization was not obtained for the out-of-network services. 
 
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 a $500 
maximum towards the cost of hearing aids per year. 
 
We looked at your request, 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 been met. Specifically, hearing aids are not a Medicare covered 
benefit. The allowance is offered as a supplemental benefit. There is no indication in the Plan's contract that 
hearing aids must be provided in-network. Therefore, we decided that the Plan has to pay the $500 benefit 
towards the hearing aids (V5261) provided on October 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (J9217). 
 
You asked the Plan to pre-approve Lupron Depot. You say that Lupron Depot is medically necessary. The Plan 
denied your request. The Plan says a trial of Eligard is required before alternatives can be considered. 
 
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 Lupron Depot. Our reviewer says that 
Lupron Depot is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drug, or any reason it would be unsafe or ineffective 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (J9217).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extracranial arteries (93880) provided on 
October 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for duplex scan of extracranial arteries. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the services were not authorized because this 
provider is a non-network provider who does not work with the member's health Plan, and the member was 
referred by a provider who also does not work with the member's Plan. The Plan also says that the member's 
primary care physician did not refer for services. 
 
 
 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 duplex scan of extracranial arteries (93880) 
provided on October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a diagnostic endoscopy and 
a specialist office visit provided on September 20, 2021. 
 
You asked the Plan to waive the deductible and copayment for a diagnostic endoscopy and a specialist office 
visit. You say that all the services provided should have been done during a prior visit to the provider. The Plan 
denied your request. The Plan says the proper deductible and copayment was applied to the services rendered. 
  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 $750 deductible which applies to is the amount you have to pay out-
of-pocket before we will pay our share for your covered medical services. There is a $125 copayment after the 
deductible is met for each outpatient surgery. Prior to the date of service, the total amount paid towards the 
$750 deductible was $678.62. Therefore, the total amount of deductible charged was $71.38 ($750 total 
deductible amount - $678.62 deductible paid prior to date of service). 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for each in-person specialist 
visit. 
 
You have been asked to pay a $71.38 deductible for a diagnostic endoscopy and a $35 copayment for a 
specialist office visit. The diagnostic endoscopy falls within the Outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers benefit category. The specialist office visit falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. This means you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation that had not been met and what you agreed to pay when you enrolled in the Plan at the 
time a diagnostic endoscopy and the specialist office visit was received on September 20, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible and copayment for a diagnostic endoscopy and a 
specialist office visit provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dentures (D5120, D5110) provided on 
August 23, 2021. 
 
You asked the Plan to waive the copayment for the dentures. You say that the services should be covered as 
you were unaware of the charges beforehand. The Plan denied your request. The Plan says the coinsurance 
applied correctly based on the services provided and there is no record of you contacting the Plan prior to 
services rendered. 
 
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% 
coinsurance for Dental services.  
 
 
  You have been asked to pay a 50% coinsurance for the dentures (total allowed is $1,658 x 50% = $854). 
Dentures fall within the Dental 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 dentures (D5120, D5110) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for office visits. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested provider is not in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for office visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial comprehensive preventive medicine evaluation and 
management service (99386) rendered by the out-of-network (OON) provider on September 16, 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 initial comprehensive preventive medicine evaluation and management service 
(99386) rendered by the out-of-network (OON) provider on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pain management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network Pain management services. You say that you were referred 
to see a specific doctor. The Plan denied your request. The Plan says this request is not for urgent/emergent 
services and that there are multiple providers within 15 miles of the member's location. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Pain management services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90834) provided on August 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records to show 
medical necessity for these claims. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and the services were not referred by a network provider. The Plan also says that they 
have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 psychotherapy (90834) provided on August 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on August 9, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you received an urgent referral from the 
enrollee's primary care physician (PCP) to treat the enrollee. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no approved authorization. It was also 
determined the referral came from an out-of-network provider and not the enrollee's PCP. 
 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 outpatient services provided on August 9, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement services (11042) 
provided on 
 
You asked the Plan to waive the copayment for the wound debridement. You say that the services should be 
covered. 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 $325 
copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $1,300 copayment for 4 wound debridement visits. Wound debridement falls 
within the 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 wound debridement services (11042) provided on
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 14, 2019, to June 24, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect RUG Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider billed a "B" level 
activities of daily living (ADL) score, which requires an ADL index of 6-10. This requires three or more 
separate instances of extensive staff support for toileting. The case file does not contain documentation that the 
enrollee required three or more separate instances of extensive staff support for toileting for the dates 6/14/19 
through 6/24/19. The reported ADL index also requires any episodes of eating assistance. The documentation 
does not support that the enrollee required eating assistance for the dates 6/14/19 through 6/24/19. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 14, 2019, to June 24, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab Services provided on December 9, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Lab Services. You say that The appellant is requesting reconsideration stating the 
services were medically necessary and provided to the member in good faith. The Plan denied your request. 
The Plan says this provider is not a network provider and we have determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 Lab Services 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 Lab Services provided on December 9, 2021 by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of speech, language, voice, communication, 
and/or an auditory processing disorder (92507) rendered by the out-of-network (OON) provider on March 22, 
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 treatment of speech, language, voice, communication, and/or an auditory 
processing disorder (92507) rendered by the out-of-network (OON) provider on March 22, 2021.