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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) on 
November 12, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were not told the 
provider no longer deals with the facility for insurance payments The Plan denied your 
request. The Plan says the correct copayment was 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 $40 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner Services, Including Doctor's 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 a specialist office visit (99204) on November 12, 2019.  
 
Your complaint about receiving erroneous or misleading information from the provider 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye surgery you had at an outpatient hospital facility, on June 5, 2020. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that you had to have two surgeries for 
the same thing, so this copayment should be waived. The Plan denied your request. The Plan says you were 
charged this copayment 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 $75 
copay,ent for outpatient procedures and services, including outpatient surgery performed in an outpatient 
hospital facility.  
 
You have been asked to pay a $75 copayment for the eye surgery. This copayment applies regardless of the 
reason for the surgery. 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 eye surgery you had at an outpatient hospital facility, on June 5, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a 
participating provider on January 4, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that this was a screening and 
not diagnostic. The Plan denied your request. The Plan says the correct copayment has been applied. The Plan 
says that the ultrasound that was performed was diagnostic in nature. 
 
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 outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $100 copayment for a diagnostic ultrasound. A diagnostic ultrasound falls within 
the outpatient diagnostic tests/diagnostic 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 copayment for a diagnostic ultrasound provided by a participating provider on January 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 5, 2019. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are 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 December 5, 2019. 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 provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing provided on 
June 15, 2020. 
 
You asked the Plan to pay more for the periodontal scaling and root planing. You say that the dental office 
knew you wanted to keep as close to your $1,000 coverage as possible. You say that if you knew the cost you 
wouldn't have done the procedure. The Plan denied your request. The Plan says your annual maximum has 
been exhausted. 
 
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, you also have an annual maximum of 
$1,000. The Plan paid $1,000 toward your dental benefits received on June 2, 2020, June 4, 2020, June 15, 
2020 and June 18, 2020, which exhausted your benefit. Any remaining charges are your responsibility. 
Therefore, we decided that the Plan does not have to pay more for the periodontal scaling and root planing 
provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on July 2, 2020 by an out of network dental provider. 
 
You asked the Plan to pay the full amount for the dental services. You say that the Quick Start Guide reads the 
same for dental services that you received in network and out of network. You also say that there is no mention 
services may be higher out of network. The Plan denied your request. The Plan says per your dental benefits, 
since the provider was out of network, the difference of billed amount and allowed amount became your 
responsibility. 
 
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 and the services you received are 
covered, the cost share may be higher when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay the full amount for the periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on July 2, 2020 by an out of network dental provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair (E0627, E1399) provided on March 22, 2019, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the lift chair. 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 by the facility 
or the provider; therefore, payment has been correctly denied. 
 
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 lift chair (E0627, E1399) provided on March 
22, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on July 17, 2020. 
 
You asked the Plan to pay for the consultation. You say that you believe this service should be covered because 
you were referred by your dentist for a procedure that he does not perform. The Plan denied your request. The 
Plan says this service is not a covered benefit under your dental plan. 
 
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 
consultation (D9310) provided on July 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cymbalta capsules for the enrollee. 
 
You asked the Plan to pre-approve Cymbalta under Medicare Part B. You say that this drug is medically 
necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Cymbalta capsules for the 
enrollee.  
 
Benefits for Cymbalta 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 copayment for the musculoskeletal injection procedure 
you had at an outpatient hospital facility on July 8, 2020. 
 
You asked the Plan to waive the copayment for the injection procedure. You say that you have had this 
procedure in the past and haven't had this high of a copayment. The Plan denied your request. The Plan says 
you had this procedure in the past prior to 2019, so your cost sharing has changed since then.  The plan says 
that you were charged this copayment 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 $500 
copayment for outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay a $500 copayment for the injection procedure. The injection procedure falls within 
the outpatient surgery at an outpatient hospital facility benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the musculoskeletal injection procedure you had at an outpatient hospital facility, on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services (11043, 11042) provided on June 9, 
2020. 
 
You asked the Plan to pay for wound care services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the units billed exceeds the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 11043 and 11042 is 1. You billed 2 units of each of these codes, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of wound care 
services have not been met. Therefore, we decided that the Plan does not have to pay for wound care services 
(11043, 11042) provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revlimid 5mg capsulses. 
 
You asked the Plan to pre-approve Revlimid. You say that Revlimid is medically necessary. The Plan denied 
your request. The Plan says Revlimid is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Revlimid 5mg capsulses.  
 
Benefits for Revlimid 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 copayment for outpatient hospital services provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you were there for 30 
minutes and you were in the doctor's office. The Plan denied your request. The Plan says the correct copayment 
has been applied. The Plan says that the clinic where this was provided is considered an outpatient hospital 
facility. 
 
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 $150 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for outpatient hospital services. Outpatient hospital services fall 
within the outpatient surgery/outpatient hospital facility benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for outpatient hospital services provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when 
specific criteria is met. 
 
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 Gel-One. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found there is a lack of documentation as to the 
on-going plans for you aside from viscosupplementation.  Therefore, the request is deemed not medically 
necessary at this point. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533 and 
A6539. 
 
You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid. The Plan 
denied your request. The Plan says the requested items are noncovered because they do not meet the statutory 
definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 and 
A6539 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533 and A6539.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve seven acupuncture visits and therapies. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the findings used to support this treatment are outdated. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 medically reasonable and necessary. Our physician reviewer found you have chronic low 
back pain, as well as neck and leg pain. The treatments you have received so far have helped decrease your 
pain scores, and helped you sleep at night. The requested service meets the criteria of NCD 30.3.3. The request 
is 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 services have been met. Therefore, we decided that the Plan has to pre-
approve seven acupuncture visits and therapies.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose CT scan for lung cancer screening provided to 
the enrollee. 
 
You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. 
The Plan says this was reported with a diagnosis that does not indicate that the enrollee was or is a smoker. 
 
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 pay for the scan. Our reviewer says that the scan at 
issue in this case was not medically reasonable or necessary. Our physician reviewer found the documents 
submitted do not include any clinical information such as smoking history, status of smoking currently or any 
other information. The acronym UPSTF means US Preventive Services Task Force and as such may reflect 
lung cancer or colon cancer screening depending on the enrollee's history. One would assume this enrollee has 
appropriate history to qualify as "high risk" for lung cancer as indicated in the dictated history but such 
information cannot be gleaned from the submitted materials. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for the low dose CT scan for lung cancer screening provided to the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET scan of the brain. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical information does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found in the physician letter of 
appeal he describes a distinct possibility of FTD in the differential and points out the temporal lobe atrophy on 
MRI 7/27/20.  Since there is a discussion including both AD and FTD as possibilities the CMS criteria for 
medical necessity are met. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
PET scan of the brain.  
 
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 continued skilled nursing facility (SNF) services beyond 
October 14, 2020. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs more therapy. The Plan 
denied your request. The Plan says the continued services are 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF 
after hospitalization for a urinary tract infection, acute kidney injury, and avascular necrosis of the left hip. He 
is walking 15 feet with a rolling walker with minimum assistance and needs minimum to moderate assistance 
with transfers and activities of daily living. He has no skilled nursing needs. He does not require skilled therapy 
on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis 
at the SNF level of care. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services beyond October 14, 2020.