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

 
We decided that the Plan does not have to waive the copayment for an outpatient visit provided on July 05, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient visit. You say that you do not agree with the 
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 $280 
copayment for each in-network outpatient hospital and observation service. 
 
You have been asked to pay a $280 copayment for an outpatient visit. This item/service falls within the each 
in-network outpatient hospital and observation 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. However, since the allowed amount is less than the standard 
copayment, you only owe $108.85. Therefore, we decided that the Plan does not have to waive the copayment 
for an outpatient visit provided on July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on June 13, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that the enrollee is in a facility and the facility 
should have obtained the prior authorization. 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 nursing facility visit 
provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits provided on January 05, 2022, to March 
03, 2022. 
 
You asked the Plan to pay for chiropractic visits. You say that this was medically necessary for this patient, 
please review and issue payment. 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 chiropractic visits 
provided on January 05, 2022, to March 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 01, 2023. 
 
You asked the Plan to pay for lab testing. You say that you have attached medical records for review. 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 lab testing provided on 
August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on May 24, 2023. 
 
You asked the Plan to pay for the injections. You say that you are requesting reconsideration of the denied 
claim. 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 injections provided 
on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 13, 2023. 
 
You asked the Plan to pay for lab testing. You say that the claim should not have denied and you are asking the 
health plan to review the medical records and process claim for payment. 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 lab testing provided on 
July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on July 21, 2023, to July 24, 
2023. 
 
You asked the Plan to pay for the chiropractic care. You say that you have submitted medical records for 
review. 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 chiropractic care 
provided on July 21, 2023, to July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 20, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 office visit provided 
on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a federally qualified health center visit and the office visit 
provided on July 06, 2023. 
 
You asked the Plan to pay for a federally qualified health center visit and the office visit. You say that you are 
requesting reconsideration of the denied claim. 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 federally qualified 
health center visit and the office visit provided on July 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for methylprednisolone injection with 
fluorscopy provided on October 12, 2021. 
 
You asked the Plan to waive the coinsurance for methylprednisolone injection with fluorscopy. You say that 
you should not have to pay for the injection. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for methylprednisolone injection with fluorscopy. This item/service falls within the Medicare Part B prescription drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for methylprednisolone injection with fluorscopy provided on October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on May 
28, 2022, to June 02, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that that you thought you 
were dying and that COVID-19 was covered 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 $290 
copayment for inpatient hospital care.  
You have been asked to pay a $290 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $1,450 for the inpatient hospital stay ($290 
copayment x 5 days = $1,450). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on May 28, 
2022, to June 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the chemotherapy services. You say that this service is medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 
chemotherapy services to be provided 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 home visit provided on July 26, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of the denied 
claim. 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 home visit provided 
on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that non-union of long bone fractures is considered to 
exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior 
to starting treatment with the electrical osteogenic stimulator. 
 
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 bone growth stimulator. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found there is 
insufficient x-ray evidence to show cessation of healing for at least 90 days to meet the criteria for a bone 
stimulator at this time. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0747).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on July 11, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 laboratory service 
provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1820). 
 
You asked the Plan to pre-approve the knee orthosis. You say that this orthosis is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis with joints (L1810, L1812) or knee 
orthosis with condylar pads and joints with or without patellar control (L1820) are covered for ambulatory 
beneficiaries who have weakness or deformity of the knee and require stabilization. 
 
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 knee orthosis. Our reviewer says 
that the orthosis is not medically necessary. Our physician reviewer found the provided documentation did not 
describe objective abnormality or instability of the knee joint. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis (L1820).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service and the implantable anchor provided 
on June 01, 2023, to June 02, 2023. 
 
You asked the Plan to pay for the laboratory service and the implantable anchor. You say that you are 
requesting reconsideration of the denied claim. 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 laboratory service 
and the implantable anchor provided on June 01, 2023, to June 02, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) Visit and self-
administered drugs (96376, 96361, 96374, 80076) provided on May 26, 2023, to May 28, 2023. 
 
You asked the Plan to waive the copayment for the ER visit self-administered drugs. You say that the services 
should be covered as you disagree with the charges. 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 $120 
copayment and $107.54 liability for the denied self-administered drugs for Emergency Care.  
 
You have been asked to pay a $120 copayment and $107.54 liability for the denied self-administered drugs for 
the ER visit self-administered drugs. 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 emergency room (ER) Visit and self-administered drugs 
(96376, 96361, 96374, 80076) provided on May 26, 2023, to May 28, 2023.  
 
If a Medicare participating provider is billing you more than the $120 copayment and the $107.54 for the 
denied self-administered drugs for the dates of service in dispute, you can contact your Kansas City CMS 
Regional Office at 816-426-5783 to ask for assistance.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 06, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the transport by an out-of-
network provider was outside of your control. 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 $290 
copayment for in and out-of-network emergency and non-emergency ground ambulance trips. 
 
You have been asked to pay a $290 copayment for ambulance services. This item/service falls within the in and out-of-network emergency and non-emergency ground ambulance trips 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 June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 02, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 office visit provided 
on June 02, 2023.