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

 
We decided that the Plan does not have to pre-approve the laboratory services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the lab services. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says the 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 laboratory services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for a transfer to a 
LTACH level of care. The Plan denied your request. The Plan says the enrollee does not meet criteria for an 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until  
 more stable and appropriate for transfer to a lower level of care soon. The enrollee does not require services at 
the LTACH that are not already available at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principal care management services provided on June 06, 
2023. 
 
You asked the Plan to pay for the principal care management 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 principal care 
management services provided on June 06, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) provided on 
January 2, 2023, to January 16, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment. 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 medication assisted treatment (G2067) 
provided on January 2, 2023, to January 16, 2023, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Monovisc joint injection provided on May 
09, 2023. 
 
You asked the Plan to waive the coinsurance for Monovisc joint injection. You say that you disagree with the 
cost share assessed. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Monovisc joint injection. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance you owe is $143.87, which is 20% of the allowed amount 
for a Medicare Part B drug injection ($719.33 allowed x 20% = $143.87). Therefore, we decided that the Plan 
does not have to waive the coinsurance for Monovisc joint injection provided on May 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
scan provided on April 06, 2023. 
 
You asked the Plan to waive the copayment for an in-network computed tomography (CT) scan. You say that 
you only have a $30 copayment for x-rays, not a $150 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 $250 
copayment for other Medicare-covered diagnostic radiology. 
 
You have been asked to pay a $250 copayment for an in-network computed tomography (CT) scan. This 
item/service falls within the other Medicare-covered diagnostic radiology 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 $151.52. Therefore, we decided that the Plan does not have to 
waive the copayment for an in-network computed tomography (CT) scan provided on April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 12, 2023. 
 
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 June 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
04, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had already met your 
out-of-pocket maximum. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for ambulance services. 
 
You have been asked to pay a $100 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. The records show your out-of-pocket maximum was processed correctly. Therefore, we decided 
that the Plan does not have to waive the copayment for the ambulance services provided on May 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on March 1, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested items is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 19, 2023, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC item provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network oncology visit provided on 
April 06, 2023. 
 
You asked the Plan to waive the copayment for an in-network oncology visit. You say that you cannot pay all 
these 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 $35 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an in-network oncology 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 in-network oncology visit provided on April 06, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the cataract surgery provided on August 24, 2022. 
 
You asked the Plan to pay for the cataract surgery. You say that the surgery was medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this procedure was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 cataract surgery. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee had a cataract causing blurred vision affecting activities of daily living; visual 
acuity was 20/40 with glare testing. Therefore, the cataract surgery was medically reasonable and necessary.  
 
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 cataract surgery have been met. Therefore, we decided that the Plan has to 
pay for the cataract surgery provided on August 24, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network urgent care visit provided on 
May 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network urgent care visit. You say that you were treated 
disrespectfully and dismissed with an active infection. You were disappointed in this treatment and feel you 
should not have to pay this 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 $25 
copayment for urgently needed services. 
 
You have been asked to pay a $25 copayment for an in-network 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 an in-
network urgent care visit provided on May 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 08, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were referred 
to the ER for a fever that developed after 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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 waive the copayment for an 
emergency room (ER) visit provided on July 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on December 30, 
2022, to January 05, 2023.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that the hospital did not move 
you to an in-network facility. 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 each day for days 1 to 6 for Medicare-covered for inpatient hospital care. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. There were five days. 5 x $250 = $1,250. Therefore, results in the total 
cost sharing amount of $1,250.  
 
You have been asked to pay a $250 copayment each day for inpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on December 30, 2022, to January 05, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services (99233) provided on 
January 18, 2022, to January 20, 2022. 
 
You asked the Plan to pay for the hospital care services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as the claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the hospital care services was not filed until June 19, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care services (99233) provided on January 
18, 2022, to January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network outpatient wrist injection 
procedure provided on April 25, 2023. 
 
You asked the Plan to waive the copayment for an in-network outpatient wrist injection procedure. You say 
that you were there for a regular appointment, then ended up getting the injection. You never left the exam 
room. 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 $275 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $275 copayment for an in-network outpatient wrist injection procedure. This 
item/service falls within the outpatient surgery and other medical 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. However, since the allowed amount is less than the standard copayment, 
you only owe $248.19. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network outpatient wrist injection procedure provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3010) provided on April 1, 2023. 
 
You asked the Plan to pay for the foot orthotics. You say that the items should be covered as you disagree with 
the charges. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3010) provided on April 
1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tubular dressing and the conform band provided on May 
23, 2023, by an OON provider.  
 
You asked the Plan to pay for the tubular dressing and the conform band. 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 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 tubular dressing and the conform band 
provided on May 23, 2023, by an OON provider.