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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on August 11, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you disagree 
with the copayment applied. 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 $195 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $195 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 $89.84, which is less than the standard copayment 
for advanced imaging services, including a CT scan. Therefore, we decided that the Plan does not have to 
waive the copayment for a computed tomography (CT) scan provided on August 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection, infliximab-dyyb, biosimilar, 
(inflectra) provided on June 29, 2023. 
 
You asked the Plan to waive the coinsurance for injection, infliximab-dyyb, biosimilar, (inflectra). You say that 
you were told that you would have a $30 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for injection, infliximab-dyyb, biosimilar, (inflectra). This 
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 injection, infliximab-dyyb, biosimilar, (inflectra) provided on June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health provided on May 30, 2023, to July 
05, 2023. 
 
You asked the Plan to pay for inpatient mental health. 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 inpatient mental health 
provided on May 30, 2023, to July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for allergen immunotherapy services provided on July 26, 2023. 
 
You asked the Plan to pay for allergen immunotherapy services. You say that this was medically necessary, 
please 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 allergen immunotherapy 
services provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation provided on July 11, 2023. 
 
You asked the Plan to pay for interrogation device evaluation. You say that you are requesting reconsideration 
for 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 interrogation device 
evaluation provided on July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ SI joint stabilization system. 
 
You asked the Plan to pre-approve the LinQ SI joint stabilization system. You say that the LinQ SI joint 
stabilization system is medically necessary. The Plan denied your request. The Plan says the LinQ SI joint 
stabilization system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LinQ SI joint stabilization system. 
Our reviewer says that the requested LinQ SI joint stabilization system is not considered medically reasonable 
and necessary. Our physician reviewer found that the enrollee was being treated for sacroiliitis not elsewhere 
classified. The enrollee presented with low back pain radiating into the bilateral posterior hips and down the 
back of the legs rated at 10/10. The exam reveals tenderness to palpation over the sacroiliac joints. Compression testing, FABER-Patricks sign, and Gaenslens are all positive. There is referred pain to the 
buttocks and groin. There is lumbosacral tenderness to palpation, decreased range of motion, and pain on 
extension and rotation. There is positive facet loading. However, detailed documentation is not evident 
regarding imaging or radiographic evidence supporting a sacroiliitis pathology. There is no clear history of SI 
joint pain onset or failure of conservative treatment directed to the SI joint. Multiple other plausible pain 
generators including at the lumbosacral spine are evident. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery 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 requested LinQ SI joint stabilization system is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve LinQ SI joint stabilization system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282) and an unlisted procedure for 
miscellaneous prosthetic services (L8499). 
 
You asked the Plan to pre-approve the wig and the prosthetic services. You say that you are requesting 
reconsideration of this denial as it is affecting your patient's overall wellbeing and is taking a toll on their 
mental health. The Plan denied your request. The Plan says a wig does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Wigs are available 
to the general public and would be helpful even to those who are not sick or injured. A wig does not meet the 
definition of medical equipment or a prosthetic device. Therefore, we decided that the Plan does not have to 
pre-approve a wig (A9282) and an unlisted procedure for miscellaneous prosthetic services (L8499).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network x-ray provided on July 21, 
2023. 
 
You asked the Plan to waive the copayment for an in-network x-ray. You say that this was part of the 
appointment you had and should not need another x-ray. 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 and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an in-network x-ray. This item/service 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 an in-network x-ray provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on July 07, 2023. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you were not aware that the 
provider was out-of-network. 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 47% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 47% coinsurance for an office visit. This item/service falls within the out-of-
network physician/practitioner services, including doctors 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. The total you owe is $41.52 ($88.34 
allowed amount x 47% = $41.52 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an office visit provided on July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapy visit provided on July 05, 2023. 
 
You asked the Plan to pay for a therapy visit. You say that this patient needs this this treatment. 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 therapy visit provided 
on July 05, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 22, 2022. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on July 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on May 26, 
2023. 
 
You asked the Plan to pay for non-emergency ambulance services. You say that these 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 non-emergency 
ambulance services provided on May 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ear wax removal procedure provided on June 01, 2023. 
 
You asked the Plan to pay for an ear wax removal procedure. You say that they took your insurance at this 
procedure and never told you it was out-of-network. 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 an ear wax removal 
procedure provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kidney transplant to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve kidney transplant. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization 
was not 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 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 
kidney transplant 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 waive the copayment for an in-network infusion procedure provided 
on July 06, 2023. 
 
You asked the Plan to waive the copayment for an in-network infusion procedure. You say that this bill is too 
high. Please reconsider. 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 $275 
copayment for Outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters. 
 
You have been asked to pay a $275 copayment for an in-network infusion procedure. This item/service falls within the Outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters 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 infusion 
procedure provided on July 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on January 24, 2023, to January 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you have been 
overcharged by this plan for many services, and you refuse to pay. 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 $375 
copayment for inpatient hospital care.  
You have been asked to pay a $375 copayment for an in-network acute inpatient 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 $750 for the inpatient hospital stay ($375 
copayment x 2 days = $750). 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 an in-network acute inpatient stay provided on 
January 24, 2023, to January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist visit provided on July 29, 
2022, to July 31, 2022. 
 
You asked the Plan to waive the copayment for each specialist visit. You say that you were admitted as 
inpatient. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for each specialist visit. This item/service falls within the 
physician/practitioner services, including doctors 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. The record shows you were under observation and 
not admitted as inpatient. The total amount you owe is $120 ($40 copayment x 3 visits = $120). Therefore, we 
decided that the Plan does not have to waive the copayment for each specialist visit provided on July 29, 2022, 
to July 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuity of care to be provided by an out-of-network 
(OON) provider for a hip arthroscopy. 
 
You asked the Plan to pre-approve the continuity of care for a hip arthroscopy. You say that the enrollee has 
had much of her care provided at the out-of-network hospital.  The Plan denied your request. The Plan says the 
hip arthroscopy is not urgent or emergent and the service is available 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 provider at issue in this case is not a network provider with the Plan. 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 continuity of care for a hip arthroscopy. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee was being treated for 
osteonecrosis of right hip. The enrollee presented with pain in the right hip with stage three osteonecrosis 
secondary to prednisone. However, detailed documentation is not evident regarding any atypical findings of the 
right hip that would require the requested care to be completed outside of network. The noted examination and 
diagnostic imaging studies demonstrate a relatively common pathology that requires specialized care from a 
specific provider over another provider in the same specialty. Therefore, there is not continuity of care issue.  
 
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 continuity of care for a hip arthroscopy have not been met.  
 
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 the continuity of care for a hip arthroscopy. Therefore, 
we decided that the Plan does not have to pre-approve continuity of care to be provided by an out-of-network 
(OON) provider for a hip arthroscopy.  
 
Please note, the enrollee may still go out-of-network to receive the surgery, but the applicable out-of-network 
coinsurances will apply.