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

We decided that the Plan has to hold you harmless for the eye refraction provided on October 2, 2019. 
 
You asked the Plan to hold you harmless for the eye refraction. You say that you should not have incurred any 
charge. The Plan denied your request. The Plan says that refractions are only covered during an annual routine 
eye exam when provided by an in-network provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You received the eye refraction service from a contract provider. The file does not show that the Plan provided 
notice that the eye refraction would not be covered. The EOC is not adequate notice of non-coverage in this 
case, as you are covered for an eye refraction under certain circumstances. Under Medicare rules, this means 
the eye refraction is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the eye refraction provided on October 2, 2019.  
 
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: Favorable

 
We decided that the Plan has to hold you harmless for vitamin-B12 and folic acid testing (82607 and 82746) 
provided on August 1, 2019. 
 
You asked the Plan to hold you harmless for the testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this is not a Medicare covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the testing by a contract provider. The file does not show that the Plan provided notice 
that the testing would not be covered. Under Medicare rules, this means the testing is considered approved by 
the Plan. Therefore, we decided that the Plan has to hold you harmless for vitamin-B12 and folic acid testing 
(82607 and 82746) provided on August 1, 2019.  
 
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 pay for the skilled nursing facility (SNF) services provided January 
10, 2020 to January 27, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF 
services. The Plan denied your request. The Plan says due to an invalid NOMNC the plan overturned dates 
January 1, 2020 to January 9, 2020. The enrollee was covered under hospice as of January 10, 2020. Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided January 
10, 2020 to January 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0434) provided on 
May 10, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be responsible 
for this charge. The Plan denied your request. The Plan says this processed 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 $225 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $225 copayment for ambulance 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 
copayment for ambulance services (A0434) provided on May 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was not diagnostic. 
The Plan denied your request. The Plan says the correct copayment has 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 $175 
copayment for outpatient surgery/ambulatory surgical center.  
 
You have been asked to pay a $175 copayment for a diagnostic colonoscopy. The colonoscopy that was 
provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic 
colonoscopy falls within the outpatient surgery/ambulatory surgical center 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 diagnostic colonoscopy provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on June 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you do not need prior authorization for this. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
rendering facility and provider are both out-of-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 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 dermatology services provided on June 23, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq and Abraxane. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has stage IIA triple negative 
breast cancer. The use of Tecentriq and Abraxane followed by anthracycline chemotherapy has been shown to 
significantly improve the enrollee's diagnosis. The drugs are considered safe and effective and reasonable and 
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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Tecentriq and Abraxane.  
 
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 prefabricated post and core provided on January 21, 
2020. 
 
You asked the Plan to pay for this service. The Plan denied your request. The Plan says that this is not a 
covered service. 
 
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 
prefabricated post and core provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 rest home visit services provided by an out 
of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive ambulance transport provided. 
 
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment. 
The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $200 
copayment for ambulance transport. 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 ambulance transport provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery and bone graft. 
 
You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
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 pre-approve gum 
surgery and bone graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 services are not among 
those covered under this benefit. The Plan only covers dental services provided by participating general dentist. 
Services with an oral surgeon are not covered. Therefore, we decided that the Plan does not have to pre-
approve dental services with an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 3, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. 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 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 lab work provided on July 3, 2020 by an out of 
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing services provided on June 17, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the GeneSight testing services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 GeneSight testing services provided on June 
17, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior instrumentation services coded 22845 provided 
on February 13, 2020. 
 
You asked the Plan to pay for the anterior instrumentation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 22845 is not supported in the medical record. Specifically, the submitted medical 
records indicate that Co-Surgeons have performed the billed service. When two surgeons perform a service as 
primary surgeons performing distinct portions of the procedure, each surgeon should report his or her distinct 
operative work by adding modifier 62 to the procedure code. Based on this information, we decided that 
Medicare rules for coverage of the anterior instrumentation services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anterior instrumentation services coded 22845 provided on February 
13, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the 3D rendering provided. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that procedure code 76377 is bundled into 70553. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that procedure code 76377 is not separately payable and bundled 
into code 70553; however, there are no NCCI edits to support that the codes are bundled. The Plan also 
references Local Coverage Article (LCA) A56526; however, this LCA is not binding for the state of New York 
where the services were performed. The Plan has not provided any valid Medicare rules or documentation to 
support that the 3D rendering is not payable. Therefore, we decided that the Plan has to pay for the 3D 
rendering provided.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for MRI tests provided on June 17, 2020. 
 
You asked the Plan to waive the copays for the services provided. You say that your original plan did not have 
a large copay. The Plan denied your request. The Plan says you are responsible for paying copays for certain 
services you receive. 
 
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 $160 
copay for each Medicare-covered radiological diagnostic service.  
 
The file shows that you received an MRI of the middle spinal canal, and an MRI of the lower spinal canal. You 
have been asked to pay a $160 copay for each MRI. The services fall within the outpatient diagnostic tests 
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 copays for magnetic resonance imaging (MRI) 
tests provided on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in the home setting and should have 
been billed with POS code 12. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammography provided. 
 
You asked the Plan to waive the copayment for diagnostic mammography. You say that as you are on a strict 
budget, it will be hard for you to pay this amount. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. The Plan also says that they have reduced the cost-sharing for this 
claim from $95.46 to $70 copayment. 
 
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 $70 
copayment for diagnostic mammography at an outpatient hospital.  
 
You have been asked to pay $70 copayment for diagnostic mammography. Diagnostic mammography 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 diagnostic mammography provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four additional extractions provided. 
 
You asked the Plan to pay for the extractions. The Plan denied your request. The Plan says the benefits for this 
service have been satisfied and the frequency limitation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to two 
procedures per calendar year. The record shows that you received six extractions, two of which 
were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the four additional extractions provided.