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

 
We decided that the Plan does not have to waive the deductible for the x-ray services provided on January 31, 
2023 
 
You asked the Plan to waive the deductible for the x-ray services. You say that x-rays are not subject to the 
deductible. 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 $150 deductible which applies to in-network x-ray services provided 
at an outpatient hospital. Your contract with the Plan also clearly says that you must pay 10% coinsurance after 
meeting the deductible for x-ray services provided at an outpatient hospital. 
 
 The deductible applies to x-ray services that are provided in an outpatient hospital. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible which applies to in-network x-ray services provided at an outpatient hospital. This cost sharing is a 
contractual obligation that had not been met at the time the x-ray services was received on January 31, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the x-ray services provided on 
January 31, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 09, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided on 
December 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the physical therapy services. You say that the in-network provider is too 
far. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 
the physical therapy 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 chiropractic manipulative treatment (CMT) provided on 
December 16, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for CMT. You say that the services should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT) 
provided on December 16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home evaluation visit provided on January 18, 2023. 
 
You asked the Plan to pay for home evaluation visit. You say that it is the responsibility of the facility to obtain 
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 home evaluation visit 
provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on January 19, 2023. 
 
You asked the Plan to pay for imaging. You say that you are requesting reconsideration for the services 
provided. 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 imaging provided on 
January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails, and trimming of skin lesions provided 
on December 01, 2022. 
 
You asked the Plan to pay for debridement of nails, and trimming of skin lesions. You say that the services 
billed are 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 debridement of nails, 
and trimming of skin lesions provided on December 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on November 04, 2022. 
 
You asked the Plan to pay for genetic laboratory testing. You say that this test is necessary to determine the 
patients needs. It is 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 genetic laboratory 
testing provided on November 04, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on November 
01, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that it is the responsibility of the 
facility to obtain 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 subsequent nursing 
facility care visits provided on November 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 reader. You say that the submitted documentation 
supports your rational as to why the enrollee needs this. The Plan denied your request. The Plan says the 
enrollee is not eligible for coverage because the initial coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 FreeStyle Libre 2 reader. Our 
reviewer says that the FreeStyle Libre 2 reader is not medically necessary. Our physician reviewer found the 
enrollee does not appear to be on any diabetes mellitus medications and there a no laboratory results suggesting 
that they have diabetes mellitus. Criteria coverage requires low blood glucose sugar or insulin use so coverage 
has not been met. 
 
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 FreeStyle Libre 2 reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 2 reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the in-network provider is too far away from 
you, and you would like to use this provider who is 15 minutes away. The Plan denied your request. The Plan 
says there are many other providers who are within the allowed distance from your residence. 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and an abdomen and pelvis 
ultrasound provided on December 08, 2022. 
 
You asked the Plan to pay for a new patient office visit, and an abdomen and pelvis ultrasound. You say that 
you found an available appointment with this provider. 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 office 
visit, and an abdomen and pelvis ultrasound provided on December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 January 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the gauze and the dressing provided on 
January 16, 2023. 
 
You asked the Plan to waive the deductible for the gauze and the dressing. You say that the items should not 
cost this much. 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 $750 deductible which applies to the gauze and the dressing.  
 
 
 
 
 You have been asked to pay $9.00 towards your deductible for the gauze. You have also been asked to pay 
$59.60 towards your deductible for the dressing. You have been asked to pay a total of $68.60 ($9.00 
deductible + $59.60 deductible = $68.60). The items or services you asked the Plan to waive the deductible for 
fall within the durable medical equipment and related supplies benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to durable 
medical equipment and related supplies. This cost sharing is a contractual obligation that had not been met at 
the time the gauze and the dressing was received on January 16, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for the gauze and the dressing provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on December 
23, 2022. 
 
You asked the Plan to pay for chronic care management services. 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 chronic care 
management services provided on December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
January 10, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services 
should be covered. 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 home visit for the 
evaluation and management provided on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on February 18, 2023. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the x-rays are normally fully 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for the 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. However, since the allowed amount is less than the standard copayment, you only owe $96.59. Therefore, we decided that the Plan does not have to waive the copayment 
for the x-ray provided on February 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit and drug injection 
provided on January 16, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visit and drug injection. You say that you 
could not do the actual procedure due to not being able to wear sneakers. 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 in-network specialist office visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network Medicare Part B drugs.  
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay $48, which is 20% 
coinsurance of the allowed amount for the drug injection ($240 allowed amount x 20% coinsurance = $48). 
You have been asked to pay a total of $88 ($40 copayment + $48 coinsurance = $88). 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 cost share for the specialist office visit and drug injection provided on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on September 30, 2021. 
 
You asked the Plan to pay for genetic laboratory testing. You say that this test is necessary to determine if the 
patient needs a transplant or not. Please reconsider. 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 genetic laboratory 
testing provided on September 30, 2021.