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

 
We decided that the Plan has to reimburse you for the monthly golf membership provided from July 21, 2018 
to December 31, 2019. We decided that the Plan does not have to reimburse you for the monthly golf 
membership provided from January 1, 2020 to March 21, 2020.  
 
You asked the Plan to reimburse you for the monthly golf membership provided from July 21, 2018 to March 
21, 2020. You say that when you joined this plan, you were told that the Plan encourages you to improve your 
health, and the Plan will cover the cost to improve your health. You also say that the practice at the golf range 
is to improve your health. The Plan says that any membership for a golf club is not covered. 
 
We decided that the Plan has to reimburse you for the monthly golf membership provided from July 21, 
2018 to December 31, 2019.  
 
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 did not provide a copy of the applicable 2018 Evidence of Coverage 
and 2019 Evidence of Coverage for this case. Without this information we cannot determine that the Plan's 
coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of 
the Plan's coverage rules and benefits. Hence, the Plan has not substantiated their denial of payment in this 
case. Therefore, we decided that the Plan has to reimburse you for the monthly golf membership provided from 
July 21, 2018 to December 31, 2019.  
 
We also decided that the Plan does not have to reimburse you for the monthly golf membership provided 
from January 1, 2020 to March 21, 2020. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only when the gym is standalone, meaning the primary purpose of the facility is to provide exercise 
equipment. 
 
The Plan's rules for coverage of gym benefits have not been met because the service in question is not covered 
under the your contract under any normal circumstances. Therefore, we decided that the Plan does not have to 
reimburse you for the monthly golf membership provided from January 1, 2020 to March 21, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an external ambulatory insulin delivery system (A9274) 
provided on January 8, 2020. 
 
You asked the Plan to pay for the external ambulatory insulin delivery system. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A9274 
has a status indicator of I which is not valid for Medicare purposes. 
 
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 A9274 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code A9274 has a status indicator of I. This means that CPT code A9274 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the external ambulatory insulin 
delivery system have not been met. Therefore, we decided that the Plan does not have to pay for an external 
ambulatory insulin delivery system (A9274) provided on January 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health outpatient visits (90837) 
provided April 22, 2020 to Mary 13, 2020. 
 
You asked the Plan to waive the copayment for the mental health visits. You say that you were under the 
impression that the provider was in network and you were informed that the copay would be $25. The Plan 
denied your request. The Plan says per the plan benefits this claim has 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 45% of 
the total allowed amount for each out of network individual visit with a psychiatrist. 
 
You have been asked to pay $62.10 for the mental health visits. The mental health visits fall within the 
Outpatient mental health care 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 mental 
health outpatient visits (90837) provided April 22, 2020 to Mary 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan of lower spine (72131) x-ray of 
lower spine (72100) x-ray of entire spine (72082) provided March 12, 2020. 
 
You asked the Plan to waive the copayment for the radiology services. You say that the plan did not pay 
anything on your claims. The Plan denied your request. The Plan says the correct copayment has been applied 
per the plan benefits. 
 
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 $435.39 
$25 copay for x-rays and $225 copay for CT scan services performed by a provider other than your primary 
care physician. for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $435.39 $25 copay for x-rays and $225 copay for CT scan services performed by a 
provider other than your primary care physician. for the radiology services. the radiology services fall 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 CT scan of lower spine (72131) x-ray of lower spine (72100) x-ray of entire spine 
(72082) provided March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) services coded 
70544 provided on December 16, 2019. 
 
You asked the Plan to pay for the MRA 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 separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
for the MRA services has a bundled relationship with code 70551 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) 
services coded 70544 provided on December 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that the services should be covered due to 
medical necessity. The Plan denied your request. The Plan says this OON care was provided without 
authorization and there are network providers able to provide this service. 
 
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 June 4, 2020 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 comprehensive oral evaluation, intraoral x-ray and 
periodontal maintenance provided on March 10, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral x-ray and periodontal maintenance. 
You say that you weren't given any information that you couldn't choose a dentist, pay the bill and get 
reimbursement. You say that the only benefit you have is the dollar amount of allowance. The Plan denied your 
request. The Plan says payment cannot be issued for services performed by a provider who has opted out of 
Medicare. 
 
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 comprehensive oral evaluation, intraoral x-ray and periodontal maintenance provided on March 10, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Kanjinti for the enrollee. 
 
You asked the Plan to pre-approve Kanjinti. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that in this setting Kanjinti is considered off-label. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Kanjinti. Our reviewer says that 
Kanjinti is medically reasonable and necessary for the enrollee in this case. The use of Kanjinti is supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal 
(Loree JM, Bailey AM, Johnson AM, et al. Molecular Landscape of ERBB2/ERBB3 Mutated Colorectal 
Cancer. J Natl Cancer Inst 2018; 110:1409. Ross JS, Fakih M, Ali SM, et al. Targeting HER2 in colorectal 
cancer: The landscape of amplification and short variant mutations in ERBB2 and ERBB3. Cancer 2018; 
124:1358.) The documentation supports that the requested drug is safe and effective and otherwise reasonable 
and necessary for this enrollee. Our physician reviewer found that the enrollee's condition meets criteria for 
coverage of Kanjinti. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kanjinti have been met. Therefore, we decided that the Plan has to pre-approve 
Kanjinti for the enrollee.  
 
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 office visit provided on January 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You did not provide an argument for coverage of this service. 
The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 had network providers available 
who could have provided 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 provided on January 9, 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 glycated hemoglobin testing provided on April 10, 2020. 
 
You asked the Plan to pay for the glycated hemoglobin testing. You say that this should be covered due to 
medical necessity. The Plan denied your request. The Plan says all tests were approved for payment other than 
the glycated hemoglobin testing as this was not performed for a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that screening testing, performed in the absence of 
signs/symptoms of disease, are not covered, other than those tests listed above. Glycated hemoglobin is 
covered for certain diagnoses as noted above. 
 
In this case, none of the reported diagnoses are listed as covered in the Medicare billing rules. There is no 
evidence presented that there was an issue with glucose levels for which this testing could be warranted. The 
documentation indicates that this was provided for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the glycated hemoglobin testing provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic electrical stimulation (G0283) provided on April 
17, 2020. 
 
You asked the Plan to pay for chiropractic electrical stimulation. You say that this should be covered because 
the provider is in-network. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic electrical stimulation (G0283) provided on April 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 to 
November 27, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you were not aware that authorization was not 
required. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the provider in this case nor the referring provider is a network provider with the Plan. The Plan had 
network providers available who could have provided 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 
November 19, 2019 to November 27, 2019 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 an injection and facility services provided 
by a participating provider on April 27, 2020. 
 
You asked the Plan to waive the copayment for an injection and facility services. You say that you weren't at a 
hospital. You say that you shouldn't have to pay a facility fee. 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 $200 
copayment for outpatient surgery/outpatient hospital.  
 
You have been asked to pay less than your $200 copayment for an injection and for facility services. The total 
amount you are being asked to pay is $217.43 ($180.08 + $37.35), which is less than the total copayment 
amount of $400 ($200 injection + $200 facility service = $400). The total amount you are being asked to pay is 
$an injection and facility services falls within the outpatient surgery/outpatient hospital benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an injection and facility services provided by a participating 
provider on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for leukocyte antibody detection (LAD) testing provided on 
January 7, 2020. 
 
You asked the Plan to pay for the LAD testing. You say that this test was ordered and intended by the 
physician as it is part of the panel that was ordered. You provided the contents of this panel and stated you 
highlighted this test on the panel testing list. The Plan denied your request. The Plan says there is no 
documentation of a valid order for the LAD testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider. 
 
In this case, the form shows that an order was placed for the Heart Smart W/O Genetics 2 panel. The testing 
included in this panel was provided and does not appear to include LAD. The test that appears highlighted is 
myeloperoxidase AB, which is not the same as the LAD testing. Without a clear indication of an order for the 
LAD testing, we find that the coverage criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for leukocyte antibody detection (LAD) testing provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulatory insulin delivery system (A9274) provided on 
April 6, 2020. 
 
You asked the Plan to pay for an ambulatory insulin delivery system. You say that this should be reprocessed. 
The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 A9274 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of an ambulatory insulin delivery system have not 
been met. Therefore, we decided that the Plan does not have to pay for an ambulatory insulin delivery system 
(A9274) provided on April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided 
by an out-of-network provider on January 14, 2020. 
 
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that you were never 
informed that the dentist was no longer in-network. You say that the dentist didn't know they were no longer 
in-network. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay 70% 
of the allowed amount for your covered dental services from an out-of-network provider.  
 
Service Allowed Amount Coinsurance Member Liability 
Oral Evaluation $45 30% $13.50 
Prophylaxis $83 30% $24.90 
TOTAL:   $38.40 
 
Therefore, we decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation 
provided by an out-of-network provider on January 14, 2020.  
 
  
Your complaint about lack of communication 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation provided 
December 13, 2019. 
 
You asked the Plan to pay for non-emergency ambulance transportation. You say that ambulance transportation 
was medically necessary. The Plan denied your request. The Plan says van transport or other vehicle, or home 
visit, may have been an option. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transportation. 
Our reviewer says that non-emergency ambulance transportation was not medically necessary in this case. Our 
physician reviewer found the documentation suggested that stretcher was required, however, there was no 
indication that a stretcher van would have been contraindication. The patient appeared to not be in any acute 
distress or have any condition which required expertise, services, or lifesaving and life-sustaining equipment 
that only an ambulance might provide. The documentation does not support that the ambulance transport was 
medically reasonable or necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance transportation provided December 
13, 2019.