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

 
We decided that the Plan does not have to pay for an office visit provided on May 09, 2023. 
 
You asked the Plan to pay for an 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 an office visit provided 
on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous sacral nerve stimulator. 
 
You asked the Plan to pre-approve percutaneous sacral nerve stimulator. You say that it is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet the requirements for approval. 
 
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 percutaneous sacral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee does not meet the requirements for approval and 
percutaneous sacral nerve stimulator trial is not medically reasonable and necessary in this case. The records do 
not clearly demonstrate that the enrollee has non-obstructive urinary retention. Also, the records state that the 
enrollee has a neurological condition (L4-5 nerve damage) that excludes coverage of neuromodulation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous sacral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous sacral nerve stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the maximum of pocket (MOOP) cost for an in-network acute 
inpatient stay provided from March 13, 2023, to March 17, 2023. 
 
You asked the Plan to waive the maximum of pocket (MOOP) cost for an inpatient stay. You say that this 
charge was only this big because you were put into a private room, which you did not ask for. You were also 
no told this service would cause such a large charge The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for inpatient medical care. ($32,266.21 allowed x 20% coinsurance = $7,253.24). However, you 
have been asked to pay $1,515.87 to meet your combined maximum out-of-pocket. Therefore the plan applied 
a coinsurance in the amount of $1,515.87 correctly. You have been asked to pay a $1,515.87 coinsurance for an inpatient stay. This item/service falls within the 
inpatient medical 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 maximum of pocket 
(MOOP) cost for an in-network acute inpatient stay provided from March 13, 2023, to March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit, and debridement of nails provided 
on July 17, 2023. 
 
You asked the Plan to pay for a new patient home visit, and debridement of nails. 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 a new patient home 
visit, and debridement of nails provided on July 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on May 03, 
2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgeries. You say that you disagree 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 $195 
copayment for outpatient surgery/Medicare-covered surgery. 
 
You have been asked to pay a $195 copayment for outpatient surgeries. This item/service falls within the 
outpatient surgery/Medicare-covered surgery 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 amount you are being asked to pay is $585 ($195 x 3 visits = 
$585). Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgeries 
provided on May 03, 2023, to May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins provided on June 15, 2023. 
 
You asked the Plan to pay for duplex scan of extremity veins. You say that it is medically necessary. The Plan 
denied your request. The Plan says that these services are not covered by your Plan. 
 
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 pay for duplex scan of extremity veins. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not provide a patient assessment and rationale for the study in question. No information is provided that would justify an out of network study. Therefore, unable 
to overturn the health plan determination on the basis of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scan of extremity veins have not been met. Therefore, we decided that 
the Plan does not have to pay for duplex scan of extremity veins provided on June 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on July 28, 2023. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you should only have a $35 
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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for an ultrasound. 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 reduce the 
copayment for an ultrasound provided on July 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint (64625). 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that you have not walked in 10 months. You 
also say that you want this procedure so you can get some relief to do daily activities. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac (SI) joint denervation (also called 
radiofrequency ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint (64625).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 6, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not 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 the home visit provided on June 6, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit provided on May 15, 2023. 
 
You asked the Plan to pay for emergency department visit. You say that this service is supported in the records. 
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 emergency department 
visit provided on May 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the out-of-network services. You say that you need this evaluation to make 
sure that you are getting the right kind of care. The Plan denied your request. The Plan says the services can be 
provided 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 
neuropsychological testing to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 06, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were directed under the Plans 
nurse to get the testing done. 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 $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $125 copayment for an ultrasound. 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. However, since the allowed amount is less than the standard 
copayment, you only owe $121.88. Therefore, we decided that the Plan does not have to waive the copayment 
for an ultrasound provided on July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve varicose veins of the lower extremity. 
 
You asked the Plan to pre-approve varicose veins of the lower extremity. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says that it is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the conservative therapy must be documented in the 
medical record. Inability to tolerate compressive bandages or stockings and the reason for such intolerance 
must be documented in the medical record. 
 
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 varicose veins of the lower extremity. 
Our reviewer says that the service is not medically necessary.  
 
Our physician reviewer found the documentation does not meet coverage criteria and does not support the 
medical necessity of the treatment in question. The documentation suggests asymptomatic but visible varicose 
veins. The mere presence of varicose veins with or without reflux is not indication for treatment. There is no 
evidence that the enrollee is having any difficulties from this including difficulties with mobility. It is 
documented that the enrollee denies lower extremity edema. There is no documentation of the following: stasis ulcer of the lower leg, significant pain and significant edema that interferes with activities of daily living, 
bleeding associated with the diseased vessels of the lower extremities, recurrent episodes of superficial 
phlebitis, stasis dermatitis, or refractory dependent edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of varicose veins of the lower extremity have not been met. Therefore, we decided 
that the Plan does not have to pre-approve varicose veins of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses (codes V2781 and V2025) purchased on March 3, 
2023, from an out-of-network (OON) provider.  
 
You asked the Plan to pay for the glasses. You say that it is your contention that neither you nor the enrollee 
knew nothing about the provider, and if you did there would be no problem. You also say that it is the failure of 
the Plan to let you know when you call to verify the treating provider was still a provider, and you believe this 
appeal should be approved. The Plan denied your request. The Plan says these items were rendered by a 
provider who is not in-network with the Plan. The Plan also says there are no calls from either the provider or 
the enrollee prior to services done to verify benefits. 
 
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 the glasses (codes V2781 and V2025) purchased 
on March 3, 2023, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate sedation (D9239), surgical removal of 
erupted tooth (D7210), bone replacement graft (D7953) and removal of torus mandibularis (D7473) provided 
on May 4, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
intravenous moderate sedation (D9239), surgical removal of erupted tooth (D7210), bone replacement graft (D7953) and removal of torus mandibularis (D7473) provided on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a decipher test. 
 
You asked the Plan to pre-approve a decipher test. You say that it is medically necessary. The Plan denied your 
request. The Plan says that the requested service is considered investigational/experimental.  
 
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 a decipher test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  
 
Our physician reviewer found that decipher testing is considered investigational and/or experimental. There is 
insufficient data to determine the net health impact, which typically means there is insufficient data to support 
that this test significantly improves health outcomes (clinical utility), and/or performs better than an existing standard of care medical management option. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a decipher test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a decipher test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided by an in-network 
provider on May 12, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that this was an annual wellness visit. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $800 deductible, and that you must pay a 10% coinsurance of the 
approved amount, and the annual deductible applies for in and out-of-network doctor and other health care 
provider services. 
 
 
 
 You have been asked to pay a $25.10 coinsurance for the office visit ($251 allowed amount x .10 = $25.10). 
You have also been asked to pay a $225.90 deductible for the office visit. The item or service you asked the 
Plan to waive the cost sharing for falls within the doctor and other health care provider services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 
deductible which applies to doctor and other health care provider services. This cost sharing is a contractual 
obligation that had not been met at the time the office visit was received on May 12, 2023. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the office visit provided by an in-network 
provider on May 12, 2023.