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

 
We decided that the Plan does not have to pay for the office visit (99213) provided on July 10, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the enrollee had changed their insurance. You 
say that authorization was not obtained for this service. You also say that the medical records show the medical 
necessity of this service. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit (99213) provided on July 10, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve otolaryngology services. 
 
You asked the Plan to pre-approve otolaryngology services. You say that it will improve the enrollee's 
breathing through the enrollee's nose. The Plan denied your request. The Plan says that the enrollee does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve otolaryngology services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has deviated nasal septum and chronic nasal 
congestion. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of otolaryngology services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve otolaryngology services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 25, 2023. 
 
You asked the Plan to pay for lab services. You say that you do not understand the denial. 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 services provided on 
July 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on May 27, 2023, to May 31, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you were 
treated terribly and were misdiagnosed. You feel you should not have to pay. 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 $315 
copayment for inpatient hospital care.  
You have been asked to pay a $315 copayment for an in-network acute inpatient stay. 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. You have been asked to pay a total of $1,260 for the inpatient hospital stay 
($315 copayment x 4 days = $1,260). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on May 27, 2023, to May 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network endoscopy procedure 
provided on April 20, 2023. 
 
You asked the Plan to waive the copayment for an in-network endoscopy procedure. You say that you have not 
had to pay a copay for this procedure in a long rime. 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 $375 
copayment for outpatient surgery. 
 
You have been asked to pay a $375 copayment for an in-network endoscopy procedure. This item/service falls 
within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network endoscopy procedure provided on April 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided on May 11, 
2023. 
 
You asked the Plan to pay for durable medical equipment (DME). You say that the supplies 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 durable medical 
equipment (DME) provided on May 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-ray provided on April 11, 2023. 
 
You asked the Plan to pay for the abdominal x-ray. 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 abdominal x-ray 
provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on July 07, 
2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you have had this service 
before and did not have to pay for it. Therefore, you feel you should not be responsible for the billed amount. 
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). The previous claims fell within the Iowa Widespread Flooding Public Health 
Emergency (active from 04/01/23 - 06/23/23) and was processed as in-network due to being within the location 
and dates of the Public Health Emergency. Therefore, we decided that the Plan does not have to pay for 
chiropractic manipulative treatment provided on July 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy provided on January 28, 2022. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you were told that the services would 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $250 copayment for the biopsy. 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. The record shows that you received a 
5% discount at the time of payment assessing the total member responsibility as $237.50. Therefore, we 
decided that the Plan does not have to waive the copayment for the biopsy provided on January 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
25, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were unaware that 
the ambulance was out-of-network. 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 $280 
copayment for ambulance services. 
 
You have been asked to pay a $280 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 June 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and the segmental 
pneumatic appliance provided on May 17, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and the segmental pneumatic appliance. 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 pneumatic 
compression device and the segmental pneumatic appliance provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on July 01, 2023. 
 
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 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 remote monitoring 
services provided on July 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on April 24, 
2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. 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 chiropractic 
manipulative treatment provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap), (90715) and administration (90471) provided on July 10, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you should not have to pay for this since your 
doctor did not advise that you would. The Plan denied your request. The Plan says these vaccines services are 
not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap), (90715) and administration (90471) provided on July 10, 2023.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve block injection provided on June 
23, 2023. 
 
You asked the Plan to waive the copayment for a nerve block injection. You say that it was your understanding 
that this was not outpatient 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 $350 
copayment for each in-network Medicarecovered outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for a nerve block injection. This item/service falls within the each in-network Medicarecovered outpatient surgery at an outpatient hospital facility 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 a nerve block injection provided on June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) for lumbar spinal stenosis (LSS). 
 
You asked the Plan to pre-approve percutaneous image-guided lumbar decompression for lumbar spinal 
stenosis. You say that you are requesting reconsideration for the denied claim. The Plan denied your request. 
The Plan says the requested procedure is still being investigated as there is a limited quality of evidence 
available to show the effectiveness of this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that effective for services performed on or after January 9, 
2014, PILD will be covered by Medicare through coverage with evidence (CED) for beneficiaries with LSS who are enrolled in an approved clinical study that meets the following criteria. The Centers for Medicare & 
Medicaid Services (CMS) has a particular interest in improved beneficiary function and quality of life, specific 
characteristics that identify patients who may benefit from the procedure, and the duration of benefit. A clinical 
study seeking Medicare payment for PILD for LSS must address one or more aspects of the following 
questions in a prospective, randomized, controlled design using current validated and reliable measurement 
instruments and clinically appropriate comparator treatments, including appropriate medical or surgical 
interventions or a sham-controlled arm, for patients randomized to the non-PILD group. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous image-guided lumbar 
decompression for lumbar spinal stenosis. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found the current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous image-guided lumbar decompression for lumbar spinal stenosis 
have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-
guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nasal cushion and the filter provided 
on August 05, 2023. 
 
You asked the Plan to waive the coinsurance for the nasal cushion and the filter. You say that you disagree with 
the coinsurance. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the nasal cushion and the filter. This item/service falls within 
the in-network durable medical equipment 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the nasal cushion and the filter provided on August 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring provided on July 09, 2023. 
 
You asked the Plan to pay for the remote monitoring. 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 remote monitoring 
provided on July 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable chest x-rays provided on May 22, 2023. 
 
You asked the Plan to pay for portable chest x-rays. 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 portable chest x-rays 
provided on May 22, 2023.