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

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on May 20, 
2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not have to pay 
this bill because the urgent care center could not treat your condition. 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 urgent 
care visit provided on May 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 15, 2023. 
 
You asked the Plan to pay for the 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 the office visit provided 
on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on April 26, 2023. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you are requesting the claim be paid in 
full. 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 outpatient clinic visit 
provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on March 24, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit, and 
related services provided on March 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on April 18, 
2022. 
 
  You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the Plan has contacted the provider to 
obtain the primary Explanation of Benefits (EOB) as they did not submit with the appeal. The Plan also says 
after multiple outreaches to the provider, the Plan did not receive any primary EOB. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has Specifically, 
the Plan made multiple attempts to obtain the primary EOB, but an EOB was not provided. As the secondary 
insurer, the Plan cannot be held responsible for the abdominal ultrasound until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for the abdominal 
ultrasound (76705) provided on April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the revascularization procedure provided 
on November 10, 2022. 
 
You asked the Plan to waive the copayment for the revascularization procedure. 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 $395 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $395 copayment for the revascularization procedure. This item/service falls 
within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 $278.58. Therefore, we decided that the 
Plan does not have to waive the copayment for the revascularization procedure provided on November 10, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
February 20, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should be responsible for this 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 $95 
copayment for in and out-of-network Medicare-covered emergency room visits. 
 
You have been asked to pay a $95 copayment for an emergency room visit. This item/service falls within the in 
and out-of-network Medicare-covered emergency room 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an emergency room visit provided on February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay March 3, 2023, 
to March 8, 2023.  
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you would like to be 
charged at the tier 1 benefit level. 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 295 
copayment per day, for days 1 to 6 and a $0 copayment per day, for additional hospital days.  
 
 You have been asked to pay a $295 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,475 ($295 copayment x 5 days = $1,475). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for an inpatient hospital stay March 3, 2023, to March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 25, 2022. 
 
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 July 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit because the enrollee is not 
participating in an approved clinical study or trial. 
 
The Plan must follow Medicare rules. Medicare rules say that monoclonal antibodies directed against amyloid 
for the treatment of AD provided outside of a trial or study are nationally non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Specifically, there is no indication in the case record that the enrollee 
is participating in an approved trial or study. Therefore, we decided that the Plan does not have to pre-approve 
Leqembi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on March 07, 
2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. 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 psychiatric 
diagnostic evaluation provided on March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the podiatry services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the podiatry services. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says this service was not approved. 
 
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 podiatry services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network otolaryngology office 
visit provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network otolaryngology office visit. You say that you 
are being charged copayments, when your card does not have that listed. 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 $5 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $5 copayment for an out-of-network otolaryngology office visit. This 
item/service falls within the physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an out-of-network otolaryngology office visit provided on 
January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hematology Profile Plus (81455) provided on December 
20, 2022.  
 
You asked the Plan to pay for the Hematology Profile Plus. You say that the enrollee's treating physician 
determined this testing to be medically necessary. The Plan denied your request. The Plan says this service 
does not meet the requirements for coverage.  
 
The Plan follows Medicare rules. Medicare rules say that NGS testing must have an FDA-approved or -cleared 
indication for use in that patients cancer. 
 
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 Hematology Profile Plus. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that there is no FDA-approved 
indication for NGS use in acute myeloblastic leukemia.  Thus, the enrollee does not meet the criteria for 
coverage. 
 
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 Hematology Profile Plus have not been met. Therefore, we decided that the 
Plan does not have to pay for the Hematology Profile Plus (81455) provided on December 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the ambulance services provided by an in-
network provider on January 13, 2023. 
 
You asked the Plan to waive the cost sharing for the ambulance services. You say that the enrollee should not 
be billed for these services. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 10% coinsurance of the approved amount for each in and out-of-network one-way ambulance trip. 
 
 The enrollee has been asked to pay a $59.57 coinsurance for the ambulance services because the Plan is only 
holding them responsible for this amount which is less than the 10% coinsurance. These items/services fall 
within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for 
the ambulance services provided by an in-network provider on January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response report provided on April 
26, 2022.  
 
You asked the Plan to pay for the GeneDose Genetic Response report. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says the clinical value and effectiveness of comprehensive 
pharmacogenetic testing have not been demonstrated in the peer-reviewed literature.  
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered when the 
criteria in the rules section of this letter 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 pay for the GeneDose Genetic Response report. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the GeneDose 
Genetic Response is not considered a screening test. The clinical value and effectiveness of comprehensive 
pharmacogenetic testing have not been demonstrated in the peer-reviewed literature. The review has 
determined that the GeneDose Genetic Response provided on April 26, 2022, was not medically necessary or 
reasonable. 
 
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 GeneDose Genetic Response report have not been met. Therefore, we 
decided that the Plan does not have to pay for the GeneDose Genetic Response report provided on April 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bunionectomy to be provided by an OON provider.  
 
You asked the Plan to pre-approve a bunionectomy. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says there are in-network providers that can 
provide this service. 
 
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 
a bunionectomy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cataract removal provided on April 05, 2023. 
 
You asked the Plan to pay for a cataract removal. You say that this was medically necessary and should be 
covered, and the plan did not specify that a referral was needed. 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 cataract removal 
provided on April 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mastectomy bra, and silicone breast 
prosthesis provided on February 06, 2023. 
 
You asked the Plan to waive the coinsurance for a mastectomy bra, and silicone breast prosthesis. You say that 
you do not understand 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered prosthetic or orthotic device, including replacement or repairs of such 
devices, and related supplies.  
You have been asked to pay 20% coinsurance for a mastectomy bra, and silicone breast prosthesis. This 
item/service falls within the each Medicare-covered prosthetic or orthotic device, including replacement or 
repairs of such devices, and related 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. The total you owe is $170.80 ($853.94 allowed amount x 20% = $170.80 
rounded up). Therefore, we decided that the Plan does not have to waive the coinsurance for a mastectomy bra, 
and silicone breast prosthesis provided on February 06, 2023.