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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 08, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have 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 $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. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 02, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and debridement provided on January 19, 
2023. 
 
You asked the Plan to pay for the office visit and debridement. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and 
debridement provided on January 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a colonoscopy provided on April 28, 2023. 
 
You asked the Plan to waive the deductible for a colonoscopy. You say that this service should be 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities.  
 
 
 
 The record shows this was a diagnostic colonoscopy. You have been asked to pay $603.09 towards your 
deductible for the colonoscopy. The item or service you asked the Plan to waive the deductible for falls within 
the outpatient surgery, including services provided at hospital outpatient facilities benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies 
to outpatient surgery, including services provided at hospital outpatient facilities. This cost sharing is a 
contractual obligation that had not been met at the time a colonoscopy was received on April 28, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on April 
28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an in-network 
provider on March 22, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you do not agree with the cost 
sharing. 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 $300 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
 
 
 
 You have been asked to pay a $140.96 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctor's office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is 
a contractual obligation that had not been met at the time the office visit was provided on March 22, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided by an in-
network provider on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on March 25, 2023, 
by an OON provider.  
 
You asked the Plan to pay for the remote monitoring services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says this 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 remote monitoring services provided on March 
25, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the drug infusion pump services provided 
from January 18, 2023, to April 11, 2023. 
 
You asked the Plan to waive the copayment for the drug infusion pump services. You say that you were not 
informed that the copayment for outpatient surgery increased. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a $50 copayment per visit for outpatient surgery or procedure at an 
outpatient hospital facility.   
 
 You have been asked to pay a $150 copayment for the drug infusion pump services ($50 copayment x 3 
services = $150). The drug infusion pump services fall 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 the drug infusion pump services provided from January 18, 2023, to 
April 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on April 19, 2023. 
 
You asked the Plan to pay for the radiology services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the radiology services 
provided on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on April 
29, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the laboratory is located 
inside your providers office. 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 $45 
copayment for in-network outpatient lab services provided by an outpatient hospital. 
 
You have been asked to pay a $45 copayment for the laboratory services. This item/service falls within the in-
network outpatient lab services provided by an outpatient hospital 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 records show the laboratory services were 
billed by an outpatient hospital facility. However, since the allowed amount is less than the standard 
copayment, you only owe $30.09. Therefore, we decided that the Plan does not have to waive the copayment 
for the laboratory services provided on April 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on April 20, 2023. 
 
You asked the Plan to pay for the x-ray services. You say that you are a Medicare certified provider of these 
services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the x-ray services 
provided on April 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
14, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had to call an 
ambulance after bleeding following a surgery. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance 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 copayment for the ambulance 
services provided on April 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 25, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should not have 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 $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $125 copayment for the 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 waive the 
copayment for the ultrasound provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing services provided on March 15, 2023. 
 
You asked the Plan to pay for the hearing services. You say that you had received authorization for these 
services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the hearing services 
provided on March 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the knee surgery and outpatient 
rehabilitation services provided from January 3, 2023, to January 4, 2023. 
 
You asked the Plan to reduce the cost share for the knee surgery and outpatient rehabilitation services. You say 
that this cost sharing is very high compared to previous surgeries. 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 in-network outpatient surgery. Your contract with the Plan also clearly says that you must pay 
a $30 copayment for each in-network physical therapy service. Your contract with the Plan also clearly says 
that you must pay a $30 copayment for each in-network occupational therapy service. 
 
You have been asked to pay $2,922.61, which is 20% coinsurance of the allowed amount for the knee surgery 
($11,456.65 allowed amount x 20% coinsurance = $2,922.61). This item/service falls within the outpatient 
surgery benefit category. You have also been asked to pay a $30 copayment for the physical therapy service, 
and a $30 copayment for the occupational therapy service. These items/services fall within the outpatient 
rehabilitation services benefit category. You have been asked to pay a total of $2,982.61 ($2,922.61 
coinsurance + $30 copayment + $30 copayment = $2,982.61). 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 cost share 
for the knee surgery and outpatient rehabilitation services provided from January 3, 2023, to January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunizations provided on October 31, 2022. 
 
You asked the Plan to pay for the immunizations. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the immunizations 
provided on October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) panel (87491, 
87591) provided April 3, 2023.  
 
You asked the Plan to pay for the services. You say that the enrollee's physician ordered the medically 
necessary Guidance UTI test as enrollee had a history of chronic urinary tract symptoms that failed to resolve 
with standard treatment.  The Plan denied your request. The Plan says the request 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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Guidance UTI testing is not standard of care and was not medically necessary in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guidance urinary tract infection (UTI) panel (87491, 87591) provided April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joystick controller display (K0108), electronic 
connection (E2311), harness (E2313), and expandable controller (E2377).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee is in 
desperate need of safe and effective mobility and pressure relief/repositioning in their home.  The Plan denied 
your request. The Plan says the multiple power options (power tilt and power recline) are not medically 
necessary. The Plan also says the joystick controller display is unbundled and cannot be approved.  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has post-polio syndrome with impaired mobility. The 
enrollee is able to use crutches although they are painful. The enrollee can walk 10-12 feet and is able to feed 
and groom and toilet themselves. Per SSA 1862 (a)1 (a) as the enrollee has sufficient strength and function in 
upper extremities to manage standard power drives. The provided records document that the enrollee is 
independent with feeding and grooming; thus, indicating the enrollee has adequate upper extremity strength 
and function to operate the wheelchairs power options with their own switches. As the electronic connection 
(E2311), harness (E2313), and expandable controller (E2377) do not meet criteria to control the wheelchairs 
power options through a joystick, the joystick controller display (K0108) is not covered. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a joystick controller display (K0108), electronic connection 
(E2311), harness (E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dexamethasone sodium phosphate, 1MG injection (J1100 
x 10 Units) rendered on August 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for.  The Plan denied your request. 
The Plan says the records do not support the services billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

We asked our coder 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 the services. Our reviewer found the procedure states 
Depomedrol was used not dexamethasone; therefore, the coding is not correct. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the dexamethasone sodium phosphate, 1MG injection (J1100 x 10 Units) rendered on August 
25, 2022.