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

We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 27, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this is your yearly breast cancer 
screening and you disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $0 
copayment for each diagnostic mammogram and a $155 copayment for radiological diagnostic services.  
 
You received an ultrasound of the breast on July 27, 2020. An ultrasound of the breast is considered diagnostic, 
not preventative. Therefore, you are responsible to pay the $155 copayment.  
 
You have been asked to pay a $155 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay more for the walker provided on July 15, 2020. 
 
You asked the Plan to pay more for the standup walker. You say that no medical supply stores carried a 
standup walker, so you bought one out-of-network. You say that you were informed insurance would pay 80%. 
The Plan denied your request. The Plan says that the coinsurance applied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must pay the non-contracting, non-
participating (non-par) DME supplier the difference between the enrollee's cost-sharing and the DME supplier's 
bill.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for more 
coverage of the walker have been met. The Plan must reimburse 80% of the full cost of the standup walker 
from the non-participating provider. (80% x $329.99 = $263.99). Therefore, we decided that the Plan has to 
pay more for the walker provided on July 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim denture (D5821) and the extraction (D7210) 
provided from July 2, 2020, to July 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that you lost a tooth while eating popcorn. You say 
that you were advised you would be reimbursed for the services. You also say that you received a notice of 
denial for the services. The Plan denied your request. The Plan says the services you received are not medically 
necessary. The Plan also says that the services you received were dental in nature. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the interim denture (D5821) and 
the extraction (D7210) provided from July 2, 2020, to July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 24, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the service you received was medically 
necessary. The Plan denied your request. The Plan says the service rendered is not covered. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services you received on June 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and needed help up. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 24, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services you received on June 24, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
February 24, 2020.
You asked the Plan to pay for the dental service. You say that the provider failed to call your insurance to
verify that the service would be covered. You say that nothing was explained to you about what services were
being provided. You also say that the service should be covered. The Plan denied your request. The Plan says 1
comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit for this
service has been exceeded.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit has been exceeded.
The record shows that the Plan paid for a comprehensive oral evaluation that you received on November 29,
2018, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on February 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from January 2, 2020, to March 27, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that these claims didn't process 
correctly. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan 
acknowledges that the claims for these months were paid out of order, however, you were still charged the 
correct total cost sharing for your SNF stay. 
 
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 $0 
copayment for days 1-20 and a $100 copayment per day for days 21-100 for skilled nursing facility care.  
 
Records show that you were in the SNF for a total of 85 days. You were not charged a copayment for the first 
20 days.  You were then charged a $100 copayment per day for days 21-35.  You met your annual out-of-
pocket maximum on day 35 of your SNF stay, so no further copayment was assessed. 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 skilled nursing facility (SNF) services you received from January 2, 2020, to March 
27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the excision of a lesion of the eyelid
provided on July 20, 2020.
You asked the Plan to waive the copayment for the excision of a lesion of the eyelid. You say that you were
told you would not owe a huge copayment and disagree with the surgery charges. The Plan denied your
request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $600
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $600 copayment for the excision of a lesion of the eyelid. The excision of a
lesion of the eyelid falls within the outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the excision of a lesion of the eyelid provided on July 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto tablets.
You asked the Plan to pre-approve Xarelto tablets. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Xarelto tablets are not covered under the enrollee's
Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto tablets.
Benefits for Xarelto tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the telephone evaluation you had with 
your primary care provider on April 10, 2020, and the lab services you received on June 29, 2020. 
 
You asked the Plan to waive the cost sharing for the telephone evaluation and the lab services. You say that 
you pay your premiums every month, so these services should be covered in full. The Plan denied your request. 
The Plan says you were charged this cost sharing 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 $15 
copayment for primary care physician services and 20% coinsurance for lab services.  
 
You have been asked to pay a $15 copayment for the telephone evaluation and 20% coinsurance for the lab 
services. 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 cost sharing for the telephone evaluation you had with your 
primary care provider on April 10, 2020, and the lab services you received on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95940) provided June 30, 2020. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the claim as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95940 is not supported in the medical record. Specifically, the claim included an invalid 
place of service. Based on this information, we decided that Medicare rules for coverage of the 
neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for 
neuromonitoring services (95940) provided June 30, 2020.
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 August 
12, 2020. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you are not paying for the 
doctor's mess ups. The Plan denied your request. The Plan says the copayment 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 $45 
copayment for each Medicare-covered urgently needed care visit. 
 
You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the 
"Urgently needed services" benefit category. The records show that you were treated during the urgent are visit. 
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 August 12, 2020.  
 
Your complaint about the doctor's messing up is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits you had with an allergist from June 30, 2020, to July 28, 2020.

You asked the Plan to waive the copayment for the allergist visits. You say that you don't think you should have to pay copayments for doctors who do nothing for you. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment for specialist visits. 

You have been asked to pay a $40 copayment for the allergist visits. The allergist visits fall within the specialist 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 the office visits you had with an allergist.  Please note that any issues you have regarding late fees or payments you have made to the doctor's office, you will need to contact the doctor's office directly
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenetic testing (81519).You asked the Plan to pre-approvethe genetic testing. You say that the test is medically necessary.The Plan denied your request. The Plan says the rules for coverage have not been met.The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when 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 pre-approve the genetic testing. Our reviewer says that the requested genetic testing is not medically necessary. Our physician reviewer found the enrollee has a clinical T1c node positive breast cancer. She has lymph node positive disease and no imaging to see how many nodes are clinically involved. The use of OncotypeDx in this situation is not reasonable or medically 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 genetic testing have not been met.Therefore, we decided that the Plan does not have to pre-approvegenetic testing (81519).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) soft tissue neck (70492).You asked the Plan to pre-approvethe CT scan. You say that you do not want to have ultrasound first. You want this procedure done so you can find out what is going on.The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested service.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pre-approve the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found CT only indicated after US has been performed.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) soft tissue neck (70492)
Appeal type: Testing
Decision: Favorable

We decided that the Plan hasto pre-approvea duplex scan of the lower extremity.You asked the Plan to pre-approveduplex scan.

You say that the enrollee needs this test.The Plan denied your request. The Plan says that the denial of authorization for this test is correct, because no ankle-brachial index has been documented.

The Plan follows Medicare rules. Medicare rules state that a duplex scan of the lower extremity may be covered under certain clinical conditions.

We asked our physician reviewer to carefully reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve duplex scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested test. Our physician reviewer found the enrollee has symptoms of claudication and evidence of vascular disease. The treating provider has ordered exercise ankle-brachial index (ABI) test. According to the Cleveland Clinic the exercise ABI is a better predictor of revascularization than standard ABI. The enrollee is at high risk for disease. It is medically reasonable and indicated to perform this test.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of duplex scan have been met.Therefore, we decided that the Plan has to pre-approvea duplex scan of the lower extremity.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (scooter).
You asked the Plan to pre-approve scooter. You say that you do not have enough strength for a walker and
need this scooter for personal care needs. The Plan denied your request. The Plan says the denial of
authorization for this device is correct, because the records do not show that you meet the criteria for a power
mobility device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 scooter. Our reviewer says that you do
not meet the Medicare criteria for this scooter. Our physician reviewer found there is no documentation that
you have a mobility deficit that impairs your participation in mobility-related activities of daily living
(MRADLs) such as toileting, feeding, grooming, and bathing in customary locations within the home. Records
indicate that this device is necessary to perform activities of daily living outside of the home. The records
indicate that you are willing and motivated to use a power mobility device, but not that you are safe to do so.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of scooter have not been met. Therefore, we decided that the Plan does not have to
pre-approve a power operated vehicle (scooter).