Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network mental health visit 
provided on May 26, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network mental health visit. You say that this should 
be covered, you should not have to pay this large amount. 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 50% 
coinsurance for outpatient mental health services. 
 
You have been asked to pay 50% coinsurance for an out-of-network mental health visit. This item/service falls 
within the outpatient mental health services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total you owe is $164 ($328 allowed amount x 50% = $164) Therefore, 
we decided that the Plan does not have to waive the coinsurance for an out-of-network mental health visit 
provided on May 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on December 21, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that someone 
else at the facility called the ambulance. You also say that you did not need the services. The Plan denied your 
request. The Plan says this service was denied because the procedure is not valid. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on December 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve out of area (OOA) Eylea injections. 
 
You asked the Plan to pre-approve out of area (OOA) Eylea injections. You say that the requested Eylea 
injections while out of the Plan's service area are medically necessary. The Plan denied your request. The Plan 
says that the enrollee can receive Eylea injections with a contracted provider. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 out of area (OOA) Eylea injections. Our 
reviewer says that the requested Eylea injections while out of the Plan's service area are medically necessary. 
Our physician reviewer found the enrollee is with a diagnosis of right exudative macular degeneration with 
active choroidal neovascularization requiring intravitreal injections in the right eye every 4 weeks. Medical 
documents show he has been receiving these treatments with the current health plan in Colorado where he 
primarily resides. He will be residing in Florida for November through December 2023 and will need these 
treatments with an out of area provider. His services were approved last year in 2022 when these were 
requested.  
 
The enrollee has foreseen requiring the services prior to leaving his service area; however, he still needs the 
injections every 4 weeks while staying in Florida for November through December 2023 and the closest in-
network provider is 8 hours away from where the enrollee is staying. The records indicate the services 
requested are medically necessary. It would not be medically reasonable to delay the services until January 
2024 when the enrollee returns to his service area. He has a very active disease process in his right eye and 
needs these injections every 4 weeks to treat and maintain his vision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of out of area (OOA) Eylea injections have been met. Therefore, we decided that 
the Plan has to pre-approve out of area (OOA) Eylea injections.   
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on March 23, 2023, to May 
15, 2023. 
 
You asked the Plan to pay for physical therapy visits. You say that you want these services reimbursed as they 
are supposed to be. 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 physical therapy visits 
provided on March 23, 2023, to May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 28, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating you should 
have submitted medical records for review as you were are not able to get a prior authorization due to being a 
small independent lab. 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 
March 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ultrasounds and an echocardiogram 
provided on April 25, 2023, to April 27, 2023. 
 
You asked the Plan to waive the copayments for the ultrasounds and an echocardiogram. You say that you were 
not aware of the copayments. 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 in-network basic radiology services in an outpatient hospital. 
 
 
 You have been asked to pay a $101.21, which is less than the standard copayment for the ultrasound provided 
on April 25, 2023. You have also been asked to pay $50, which is less than the standard copayment for the 
ultrasound provided on April 26, 2023. You have also been asked to pay $95.29, which is less than the standard 
copayment for the ultrasound provided on April 27, 2023. These items/services fall within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ultrasounds and 
an echocardiogram provided on April 25, 2023, to April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided April 4, 2023.  
 
You asked the Plan to pay for the laboratory service. You say that this test should be considered in patients 
thought of be of higher risk despite a negative biopsy. The Plan denied your request. The Plan says the criteria 
is not met for as the enrollee was not being considered for a repeat biopsy due to persistent risk factors such as 
elevated/rising PSA and/or abnormal DRE by repeat testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. ConfirmMDx was ordered on the same day as biopsy and ordered 
prematurely.  Per the office staff there is no order for repeat biopsy. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for ConfirmMDx testing (81551) provided April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D6752 and D2950). 
 
You asked the Plan to pre-approve the dental services (D6752 and D2950). You say that you are requesting 
reconsideration stating that you have abscess on gums twice which made the side of your face swollen. You 
state your teeth hurt and can barely eat. The Plan denied your request. The Plan says the dental service D2950 
is not a covered benefit and service D6752 would exceed the benefit's frequency limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service D2950 is not 
among those covered under this benefit. The dental service D6752 has a frequency limit of one bridge 
retainer crown every five years.  Therefore, we decided that the Plan does not have to pre-approve the dental 
services (D6752 and D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 10, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 10, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
10, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 10, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 10, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 10, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 10, 
2023, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure device (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show there is no formal 
shared decision-making interaction with an independent, non-interventional physician. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such 
as if there is a formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool. 
 
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 LAAC. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found records do not document that a formal 
decision-making interaction with a non-interventional physician was performed. As such, guidelines would not 
support implantation of a LAAC in this setting. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve left atrial appendage closure device (LAAC) (33340).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment provided on May 01, 2023. 
 
You asked the Plan to pay for opioid treatment. You say that you say that you are requesting reconsideration 
the walk-in clinic is not contracted with the Plan and is not required to do referrals or 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 opioid treatment 
provided on May 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LLE ablation (36482), phlebectomy (37765, 37766), 
and sclerotherapy (36471). 
 
You asked the Plan to pre-approve LLE ablation, phlebectomy, and sclerotherapy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that varicose vein treatment is covered when specific 
criteria are met. 
 
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 LLE ablation, phlebectomy, and 
sclerotherapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
medical necessity has not been established. Therefore, coverage criteria have 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 LLE ablation, phlebectomy, and sclerotherapy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve LLE ablation (36482), phlebectomy (37765, 37766), and 
sclerotherapy (36471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on May 17, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the chiropractic services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 chiropractic services provided on May 17, 
2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network colonoscopy provided on 
May 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network colonoscopy. You say that you were told that 
this would be covered 100%, and you were not advised that polyp removal would case a copay. 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 $350 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for an in-network colonoscopy. This item/service falls within 
the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an in-network colonoscopy 
provided on May 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy services provided on 
May 15, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that you did not expect a 
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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for the physical therapy services. This item/service falls within 
the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the standard copayment, you 
only owe $28.88. Therefore, we decided that the Plan does not have to waive the copayment for the physical 
therapy services provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on September 06, 
2022, to September 07, 2022. 
 
You asked the Plan to waive the copayment for each office visit. You say that you should not have to pay these 
copayments while in observation. 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 $30 
copayment for specialist visits. 
 
You have been asked to pay a $30 copayment for each office visit. This item/service falls within the specialist 
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 amount you owe is $60 ($30 copayment x 2 visits = $60). Therefore, we decided that the Plan does 
not have to waive the copayment for each office visit provided on September 06, 2022, to September 07, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on August 29, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration for 
the service 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 skilled nursing facility 
care provided on August 29, 2022, to August 31, 2022.