Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic 
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve 
(92133) provide on May 28, 2020. 
 
You asked the Plan to waive the copayment for scanning computerized ophthalmic diagnostic imaging, 
posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. You say that you should 
not be responsible for a cost share. The Plan denied your request. The Plan says the cost share was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $30 copayment for scanning computerized ophthalmic diagnostic imaging, 
posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. This 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 scanning computerized ophthalmic diagnostic imaging, posterior segment, with 
interpretation and report, unilateral or bilateral; optic nerve (92133) provide on May 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography (77067) screening digital breast 
tomosynthesis (77063) provided November 11, 2019. 
 
You asked the Plan to pay for the diagnostic services. You say that the plan paid for the procedure then took 
the payment back. You have attached the report for review to pay back per contract. The Plan denied your 
request. The Plan says the claim must be submitted to the primary payer. 
 
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 is the secondary 
payor. As the secondary insurer, the Plan cannot be held responsible for the diagnostic services until the 
primary insurer has denied the claim for these services. 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for screening mammography (77067) screening 
digital breast tomosynthesis (77063) provided November 11, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient services provided from September 19, 2020, to 
September 22, 2020. 
 
You asked the Plan to pay for the acute inpatient services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the enrollee could have been treated in an alternative care 
level. 
 
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 acute inpatient services. Our reviewer 
says that the services are considered medically reasonable and necessary in this case. Our physician reviewer 
found dialysis is different as it is a lifesaving/preserving procedure. The enrollee was unable to get dialysis as 
an outpatient and had an issue with access. In addition, the enrollee was mildly hyperkalemia such that if the 
access did not work or if there was a missed treatment, a life threatening event could occur. The admission was 
medically indicated and 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 acute inpatient services have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient services provided from September 19, 2020, to September 22, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that this testing is covered by Medicare and provides 
valuable information for physicians. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-
network with the Plan. 
 
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 has network providers 
available who can provide 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 medical services provided on July 17, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of erupted tooth (D7210) and consultation 
(D9310). 
 
You asked the Plan to pre-approve the extraction of erupted tooth and consultation. You say that an oral 
surgeon needs to perform these services due to your medical needs. The Plan denied your request. The Plan 
says coverage is only provided when the dental services are performed by a participating general dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the extraction 
of erupted tooth and consultation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The information indicates that you will not be receiving these dental 
services from a contracted dentist. Based on this information, we decided that the Plan's rules for coverage of 
the extraction of erupted tooth and consultation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the extraction of erupted tooth (D7210) and consultation (D9310).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not to waive the coinsurance for injections and copayment for diagnostic radiology and an 
EKG provided by participating providers on June 1, 2020. 
 
You asked the Plan to waive the coinsurance for injections and copayment for diagnostic radiology and an EKG. You say 
that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance and 
copayment have been applied. 
 
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 20% coinsurance 
for Medicare Part B prescription drugs, a $110 copayment for outpatient diagnostic tests/radiology services and a $30 
copayment for outpatient diagnostic tests/non-radiology services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for injections, a $110 copayment for diagnostic 
radiology and a $30 copayment for an EKG. The total allowed amount is $494.52 x 20% = $98.90. The total amount you 
are being asked to pay is $238.90 ($98.90 + $110 + $30 = $238.90). Injections falls within the Medicare Part B 
prescription drugs benefic category. Diagnostic radiology and an EKG fall within the outpatient diagnostic 
tests/radiology services benefit category and outpatient diagnostic tests/non-radiology 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 coinsurance for injections and copayment for diagnostic radiology and an EKG provided by participating 
providers on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for AlloSure testing provided on June 18, 2020. 
 
You asked the Plan to pay for AlloSure testing. You say that this testing is covered by Medicare. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this testing is only 
covered for kidney transplant patients however the enrollee is a heart transplant patient. 
 
The Plan must follow Medicare rules. Medicare rules say that, for date of service June 18, 2020, AlloSure 
testing must be billed with CPT code 81479 and is only covered for diagnosis codes T86.10 or Z94.0.  
 
We looked at the file and Medicare rules. This testing was not billed with an appropriate code and was not 
performed for a covered diagnosis. Based on this information, we decided that Medicare rules for coverage of 
AlloSure testing have not been met. Therefore, we decided that the Plan does not have to pay for AlloSure 
testing provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of 
bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210). 
 
You asked the Plan to pre-approve surgical removal of erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated. You say that the service was 
medically necessary. The Plan denied your request. The Plan says a less severe extraction code would be 
considered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers surgical 
removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated when the services are medically necessary and reasonable.  
 
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 surgical removal of erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
surgical extractions of teeth 22-25 (D7210) does not meet the criteria for coverage.  It appears that extraction 
via elevation and/or forceps removal (D7140) would be applicable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of surgical removal of erupted tooth requiring removal of bone and/or sectioning 
of tooth, and including elevation of mucoperiosteal flap if indicated have not been met. Therefore, we decided 
that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is subject to prior authorization. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found per the documentation, he is only on Lantus once per day without any mealtime insulin. There have been 
no reported wide fluctuations noted in blood glucose readings which are tested 2 times per day. The review has 
determined that in this case, the monitor is not considered therapeutic. There is a diagnosis of diabetes mellitus 
but the enrollee has not been using insulin multiple times (3 or more) a day. The enrollee's treatment does not 
require frequent adjustment on the basis of testing results. 
 
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 pre-approve the Dexcom G6 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration provided. 
 
You asked the Plan to pay for chemotherapy administration (96420). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the 
facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside providers.  
 
This was an inpatient service. Payment for this service would have been included under the global facility claim. Payment 
to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare 
rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have 
to pay for chemotherapy administration provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dermatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dermatology. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to 
seek out-of-network care. The Plan says there are equally qualified in-network dermatologists available to you 
that can provide the care you are requesting. 
 
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 dermatology services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an abdominal ultrasound (76705) provided on June 22, 2020. 
 
You asked the Plan to pay for an abdominal ultrasound. You say that the enrollee had multiple exams on this 
date of service. The Plan denied your request. The Plan says that this procedure is included in a previously 
billed procedure per NCCI edits. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits. 
 
We looked at the file and Medicare rules. Though this was denied for NCCI edits, the service that the billed 
code has a column one/column two relationship with was provided by a different provider. Although these 
services have the same billing provider, the renders providers have different NPIs and the NPIs do not show 
that they belong to the same group practice. Based on this information, we decided that Medicare rules for 
coverage of an abdominal ultrasound have been met. Therefore, we decided that the Plan has to pay for an 
abdominal ultrasound (76705) provided on June 22, 2020.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from April 25, 2020, to April 26, 2020. 
 
You asked the Plan to pay for inpatient care. You say that these services were medically reasonable and 
necessary. The Plan denied your request. The Plan says that the denial of payment for this inpatient care is 
correct, because as of 10:01am on April 25, 2020 the enrollee's condition was stabilized and the enrollee could 
have been transferred to an in-network hospital for post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
 
 
 
 
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 inpatient care. Our reviewer says that these 
inpatient hospital services meet the Medicare criteria for coverage. Our physician reviewer found therapy was 
appropriate and indicated. At the time the Plan's denial began, the enrollee was not yet accepted for admission 
by the Plan. In addition, the COVID-19 status of the enrollee adds complexity to the transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have been met. Therefore, we decided that the Plan has to pay for 
inpatient hospital care provided from April 25, 2020, to April 26, 2020.  
 
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above 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 daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services (92015) during a medical eye 
examination provided on August 10, 2020. 
 
You asked the Plan to pay for the eye refraction services. You say that this was a required exam and should be 
covered. The Plan denied your request. The Plan says eye refraction charges are only covered when billed as 
routine. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided during a routine vision examination.  
 
We looked at the file and the Plan's rules. The file indicates that you did not receive the eye refraction services 
during a routine vision exam but instead during a medical eye exam. Based on this information, we decided 
that the Plan's rules for coverage of the eye refraction services have not been met. Therefore, we decided that 
 
 
the Plan does not have to pay for the eye refraction services (92015) during a medical eye examination 
provided on August 10, 2020.