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

 
We decided that the Plan does not have to pay for wound care provided on March 13, 2020. 
 
You asked the Plan to pay for the wound care. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization.  
 
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 
wound care. 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 wound care provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Vyepti (at the higher 300mg starting dose). 
 
You asked the Plan to pre-approve Vyepti. You say that the medication is necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vyepti. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that the requested Vyepti in this case 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 Vyepti have been met. Therefore, we decided that the Plan has to pre-approve 
Vyepti (at the higher 300mg starting dose).  
 
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 copayment for an MRI scan of the brain (70551) 
performed on July 10, 2020. 
 
You asked the Plan to waive the copayment for an MRI scan of the brain. You say that this MRI scan should 
not have been necessary. 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 $275 
copayment for each advanced imaging service.  
 
You have been asked to pay a $179.02 copayment for an MRI scan of the brain. An MRI scan of the brain falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay less than the full 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 MRI scan of the brain (70551) performed on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on September 3, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this should be covered because you had 
insurance. The Plan denied your request. The Plan says this 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 office visit (99213) provided on September 3, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan on 
April 21, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the Plan should pay the balance. 
The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $235 
copayment for each covered diagnostic procedure or test at a network outpatient facility.  
 
Review of the file shows that you received a CT scan on April 21, 2020. Per the contract with the Plan, there is 
a $235 copayment for each covered diagnostic procedure or test at a network outpatient facility. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare 
allowed amount for these services was $107.31. Given that the allowed amount was less than the $235 
copayment, you have been asked to pay $107.31 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) 
scan on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and venipuncture (blood 
draw) provided by an out-of-network provider on July 1, 2020. 
 
You asked the Plan to waive the deductible for office services. You say that you were told by this provider's 
office that they are in-network. The Plan denied your request. The Plan says the deductible amount you are 
being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible for out-of-network office visit and blood draw. At 
the time this claim was processed, $0 of the $1,000 deductible had been met. The allowed amount of the claim 
is $106.46, resulting in a deductible obligation of $106.46. 
 
The items or services you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $1,000 deductible for Physician/Practitioner Services, Including 
Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time office 
services was received on July 1, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for an office visit and venipuncture (blood draw) provided by an out-of-network provider on July 1, 
2020.  
 
Your complaint regarding receiving inaccurate information about the network status of this provider is 
considered to be a grievance. We do not have the jurisdiction to address grievances. 
Please contact the Plan for more information about your grievance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided May 11, 
2020 to May 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. 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 $275 
per day copayment for days 1-6 of inpatient care. 
 
You have been asked to pay a $275 per day copayment for 3 days of inpatient hospital care ($825). 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 inpatient hospital care provided May 11, 2020 to May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on July 2, 2020 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not know that you had 
to wait 3 years to receive this service again. The Plan denied your request. The Plan says your benefit 
maximum has been met for this 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, comprehensive oral exams are limited 
to once every 36 months. The record shows that you received a comprehensive oral evaluation on February 2, 
2019, and your comprehensive oral exams benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation provided on July 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient facility services provided March 26, 2020 to 
March 28, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services 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 24515 is not supported in the medical record. Specifically, the submission of a device-
dependent procedure also requires that a device be submitted on the same claim/day. The procedure billed is a 
device-dependent procedure and no device CPT code was billed on the claim at issue. Based on this 
information, we decided that Medicare rules for coverage of the outpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for outpatient facility services provided March 26, 
2020 to March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis 
provided on June 10, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that this 
provider was paid in the past by your previous plan. The Plan denied your request. The Plan says these services 
were rendered by a Medicare opt out provider. The Plan also says that charges incurred by Medicare opt out 
providers will not be reimbursed by the Plan. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation, bitewings, and prophylaxis provided on June 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle x-ray provided on May 16, 2020. 
 
You asked the Plan to pay for the ankle x-ray. You say that the enrollee was only on hospice from April 22, 
2020, to May 4, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 4, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ankle x-ray provided on 
May 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Tocilizumab infusions (J3262, 96365) 
provided January 15, 2020 to March 12, 2020. 
 
You asked the Plan to waive the copayment for Tocilizumab infusions. You say that you were reassured that 
your infusions would be covered under the pharmaceutical portion of your benefits. You cannot afford to pay 
for these charges and would like consideration. The Plan denied your request. The Plan says the 20% 
coinsurance applied correctly per the Evidence of Coverage. 
 
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 20% 
coinsurance for each Medicare covered Part B drug for Medicare Part B prescription drugs.  
 
You have been asked to pay $620.60 for the Tocilizumab infusions. The provider billed $13,555.81. The plan 
paid $12, 935.21.  The Tocilizumab infusions falls within the Medicare Part B prescription drugs 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 Tocilizumab infusions (J3262, 96365) provided 
January 15, 2020 to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinical visit (G0463) provided on 
February 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinical visit. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization is required for out-of-
network providers. 
 
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 hospital outpatient clinical visit (G0463) 
provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses (V2020). 
 
You asked the Plan to pre-approve eyeglasses. You say that you cannot see without glasses. The Plan denied 
your request. The Plan says you have exceeded the benefit limit. 
 
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 offers a supplemental benefit of up to $300 for eyeglasses every two years. 
 
We looked at the file and the Plan's rules. The record shows it has been less than two years since you last 
received eyeglasses. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have 
not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses (V2020).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 1, 2020 to April 30, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the radiation services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says prior authorization is required and 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 the medical services provided on April 1, 2020 to 
April 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on March 4, 
2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says payment for this service is 
included in payment to the facility and not separately reimbursable for this provider in this place of service. 
 
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 99153 is not supported in the record. Specifically, CPT code 99153 is a "technical only" 
code and Medicare considers that the independent trained observer represents an expense to the facility and 
may only be billed by the facility. Based on this information, we decided that Medicare rules for coverage of 
the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
moderate sedation services (99153) provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants, abutments, crowns, and related dental 
services. 
 
You asked the Plan to pre-approve the dental implants, abutments, crowns, and related dental services.. You 
say that you have severe medical issues surrounding your mouth and jaw, and are also suffering from TMJ and 
lip disease. You also say that you have undergone several treatment options to resolve your issues, but all of 
them have failed. The Plan denied your request. The Plan says the supplemental dental lists only the specific 
services which are covered which does not include dental implants, abutments, and crowns. 
 
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 
dental implants, abutments, crowns, and related dental services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services 
provided June 9, 2020 to June 10, 2020. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you do not feel 
you should have to pay for an observation copayment because you were not told that there would be a charge. 
You have no money and will only pay the $90 emergency room fee but no more. The Plan denied your request. 
The Plan says the claim processed and the correct copayment was applied per the Evidence of Coverage. 
 
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 $150 
copay per stay.  
 
You have been asked to pay $150 copay for the hospital observation services. The hospital observation services 
fall within the outpatient hospital observation 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 outpatient hospital observation services provided June 9, 2020 to June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on November 11, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were not billed correctly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on November 11, 2019.