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

 
We decided that the Plan does not have to pay for the telehealth services (99442) provided by an out of network (OON) provider. 
 
You asked the Plan to pay for OON telehealth services. You say that you were not able to obtain a referral. The 
Plan denied your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 telehealth services (99442) provided by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on September 10, 2020. 
 
You asked the Plan to waive the copayment for dermatology services. You say that you still are breaking out 
and she did not help at all. 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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for dermatology services. Since a dermatology office visit was 
provided, the correct copayment has been applied. Dermatology services fall within the physician/practitioner 
services/specialist 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 provided by a participating provider on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 6, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 physician services provided to the enrollee on July 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided. 
 
You asked the Plan to pay for digital breast tomosynthesis. You say that this is supported in the records. The 
Plan denied your request. The Plan says this was billed with an invalid code. 
 
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 77062 is not supported in the medical record. Specifically, this code has a status 
indicator of Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of digital breast tomosynthesis have not been met. 
Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve respiratory infectious agent detection provided to the 
enrollee on March 19, 2020. 
 
You asked the Plan to pre-approve the testing. You say that  The Plan denied your request. The Plan says 
respiratory infectious agent detection, code 87633, is non-covered by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory infectious agent detection of 6 or 
more pathogens is not covered. 
 
The code at issue in this case - CPT 87633 - is for 12-25 targets. This code cannot be covered. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve respiratory infectious agent detection provided to the 
enrollee on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on March 19, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says all cardiovascular risk assessment panels are excluded, except for the basic lipid panel, 
for symptomatic patients with suspected or documented cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. Medicare does not cover cardiovascular risk 
assessment panels. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have 
to pay for testing services provided to the enrollee on March 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that inpatient services should be billed on an 11x type of 
bill.  
 
We looked at the file and Medicare rules. The provider billed procedure code 23472 (total shoulder 
arthroplasty) with an outpatient hospital TOB code. This procedure is on the inpatient only list and is not 
payable under outpatient billing. 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 pay for the surgical 
services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth specialist services provided 
on July 23, 2020. 
 
You asked the Plan to waive the copayment for the telehealth specialist services. You say that there should not 
be a copayment. The Plan denied your request. The Plan says you have been charged a 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 $40 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $25 copayment for the telehealth specialist services. The telehealth specialist 
service falls within the Specialist Physician/Practitioner services benefit category. This means that you have 
been asked to pay less than the required 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 telehealth specialist services provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the H. influenzae type B, poliovirus, and tetanus-diphtheria-
acellular pertussis (Tdap) vaccines provided on June 19, 2020. 
 
You asked the Plan to pay for the vaccines. You say that you feel that these vaccines should be covered since 
they were required due to a stem cell transplant. The Plan denied your request. The Plan says these 
vaccinations are not among the types covered by Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccines. 
Therefore, we decided that the Plan does not have to pay for the H. influenzae type B, poliovirus, and tetanus-
diphtheria-acellular pertussis (Tdap) vaccines provided on June 19, 2020.  
 
Benefits for the vaccines 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: Lab
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 March 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on June 13, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. The Plan stated that it was unable to discover any 
evidence of an established relationship between the member and the ordering physician. There were no claims 
submitted for an evaluation and management service. Review of claims history for this enrollee and a review of 
the submitted documentation did not contain evidence of a relationship with the ordering physician as required 
per CMS guidelines. Therefore, the billed service cannot be verified 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide documentation to support the services 
billed. In this case, the medical records provided do not support the services billed. Medicare rules for coverage 
of this service have not been met as a treating relationship cannot be verified. Therefore, we decided that the 
Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on June 13, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eye refraction provided on July 22, 2020. 
 
You asked the Plan to pay for an eye refraction. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that you do not have coverage for this service. 
 
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 one routine eye exam per calendar year. 
 
We looked at the file and the Plan's rules. The record does not show that you have previously exhausted your 
one supplemental routine eye exam for the 2020 calendar year. Based on this information, we decided that the 
Plan's rules for coverage of eye refraction have been met. Therefore, we decided that the Plan has to pay for 
eye refraction provided on July 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 27, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 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 subsequent nursing facility care provided on August 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan. 
 
You asked the Plan to pre-approve a duplex scan. You say that the requested duplex scan is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet LCD criteria for the 
requested Duplex scan. 
 
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 a duplex scan. Our reviewer says that 
the enrollee does not meet LCD criteria for the requested Duplex scan. Our physician reviewer found the 
documentation does not meet coverage criteria and does not support the medical necessity of the study in 
question.  There is no description of patient complaints in the medical records provided.  There is no 
documentation of a physical examination.  There is no documentation of previous carotid surgery or carotid 
disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a duplex scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says the pain is described as radicular. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is a radicular component to the enrollee's pain. Therefore, this request is considered not medically 
reasonable or 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lumbar/sacral facet joint block for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for a diagnostic eye exam (99204) provided on 
June 25, 2020. 
 
You asked the Plan to lower the copayment for a diagnostic eye exam. You say that you were told this would 
have a routine eye exam copayment. 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 $45 
copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye.  
 
You have been asked to pay a $45 copayment for a diagnostic eye exam. The submitted medical records 
confirm that the eye exam at issue was diagnostic rather than routine. 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 lower the 
copayment for a diagnostic eye exam (99204) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for a chemodenervation procedure (64616). 
 
You asked the Plan to waive the co payment for a chemodenervation. You say that you have been getting these 
services for years. The Plan denied your request. The Plan says the correct co payment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
co payment for nuclear medicine services.  
 
You have been asked to pay a $325 co  payment for a chemodenervation. A chemodenervation falls within the 
"Outpatient hospital 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 co payment for a 
chemodenervation procedure (64616) performed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on July 7, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you told the provider's office that you 
only wanted to receive covered services. You also say that the provider's office told you that the treatment 
would be paid in full by your insurance. The Plan denied your request. The Plan says this service is not covered 
under the 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 
preventive procedure (D1999) provided on July 7, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Neulasta injections (J2505). 
 
You asked the Plan to pre-approve Neulasta injections. You say that Neulasta injections are medically 
necessary. The Plan denied your request. The Plan says that rules for pre-approval have not been met. 
 
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 Neulasta injections. Our reviewer says 
that the requested drug is safe and effective and otherwise reasonable and necessary for the enrollee. Our 
physician reviewer found that Neulasta is approved by the Food and Drug Administration (FDA) to decrease 
the incidence of infection (as manifested by febrile neutropenia) in patients with nonmyeloid malignancies 
receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile 
neutropenia. Although the chemotherapy regimen of carboplatin/etoposide is associated with a moderate risk of 
febrile neutropenia the enrollee has the additional risk factor of age greater than 65 putting her risk of 
neutropenic fever to greater than 20% and, therefore, high risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta injections have been met. Therefore, we decided that the Plan has to 
pre-approve Neulasta injections (J2505).  
 
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 waive the copayment for a laryngoscopy (31579) provided August 
20, 2020. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you should not be charged 
because this was related to COVID-19. 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 $350 
copayment for outpatient procedures and services, including but not limited to diagnostic and therapeutic 
endoscopy, and outpatient surgery.  
 
You have been asked to pay a $350 copayment for a laryngoscopy. 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 laryngoscopy (31579) provided August 20, 2020.