Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure monitor. 
 
You asked the Plan to pre-approve the blood pressure monitor. You say that you were told that you needed to 
obtain an override in order to purchase the requested device over the counter. You say that it is taking too long 
to complete this request. The Plan denied your request. The Plan says this is not a covered device through 
original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography, transthoracic (99306) 
diagnostic ultrasound procedures of the head and neck (76536) duplex scan of extracranial arteries (93880) 
provided August 19, 2020. 
 
You asked the Plan to waive the copayment for the radiological diagnostic services. You say that please review 
these claims. You believe there was a lack of transparency. You experienced one partial upper body test and 
ultra sound of neck for thyroid nodules. The Plan denied your request. The Plan says the claims processed and 
the correct copayment was applied per the Evidence of Coverage. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $125 for each radiological diagnostic service, not including x-rays, 
performed in a physician's office or at a free standing facility, such as a radiology center or medical clinic. 
 
You have been asked to pay $335.05 ($85.05 + $125 + $125) for the radiological diagnostic services. The 
radiological diagnostic 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 echocardiography, transthoracic 
(99306) diagnostic ultrasound procedures of the head and neck (76536) duplex scan of extracranial arteries 
(93880) provided August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection (95117) provided October 1, 
2020. 
 
You asked the Plan to waive the copayment for the injection. You say that the service was always covered in 
full in the past. 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 $15 
copayment for Part B drugs that are professionally administered.  
 
You have been asked to pay a $11.66 copayment for the injection. The injection falls within the Part B Drugs 
benefit category. The Medicare allowed amount of $11.66 is less than the $15 copayment listed in the plan 
contract. 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 (95117) provided October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood pressure monitor. 
 
You asked the Plan to pre-approve these services. You say that your doctor advised you keep your blood 
pressure on track. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for occupation therapy provided by a 
participating provider from October 2, 2020, to October 6, 2020. 
 
You asked the Plan to waive the deductible for occupation therapy. You say that you shouldn't owe anything 
for this. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
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 a $750 deductible for outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not 
been met at the time occupation therapy was received from October 2, 2020, to October 6, 2020. The total 
amount you are being asked to pay is $209.09. Therefore, we decided that the Plan does not have to waive the 
deductible for occupation therapy provided by a participating provider from October 2, 2020, to October 6, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction (D7210) you received on August 6, 
2020. 
 
You asked the Plan to pay for the extraction. The Plan denied your request. The Plan says this is not a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in 
the Evidence of Coverage. Dental code D7210 is not listed, and therefore is not covered. Therefore, we decided 
that the Plan does not have to pay for the dental extraction (D7210) you received on August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of nivolumab (J9299) and an injection of 
ipilimumab (J9228). 
 
You asked the Plan to pre-approve an injection of nivolumab and ipilimumab. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 an injection of nivolumab and 
ipilimumab. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
service is not FDA approved with the progression of the enrollee's 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 an injection of nivolumab and ipilimumab have not been met. Specifically, the 
service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-
approve an injection of nivolumab (J9299) and an injection of ipilimumab (J9228).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete blood count services received on August 18, 
2020. 
 
You asked the Plan to pay for the complete blood count services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the complete blood count services, were requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. In addition, you signed paperwork 
that stated these services were not covered and that you would be held responsible for these services. 
Therefore, we decided that the Plan does not have to pay for the complete blood count services received on 
August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
July 23, 2020 to October 1, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for 
the copayments because they were follow-up appointments following surgery. The Plan denied your request. 
The Plan says the claims were processed and the correct copayment 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 $45 for 
each visit with a specialist.  
 
You have been asked to pay $45 for the office visits. The office visits fall 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 the outpatient office visit (99213) provided July 23, 2020 to October 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health care provided from December 16, 
2019, to December 17, 2019. 
 
You asked the Plan to pay for the inpatient mental health care. You say that the inpatient mental health care 
provided was medically necessary. The Plan denied your request. The Plan says beginning December 16, 2019, 
inpatient psychiatric treatment was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
reviewer says that the inpatient mental health care was not medically necessary. Our physician reviewer found 
this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was 
not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative 
with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services were reasonably expected to improve the patient's condition or for the purpose of 
diagnosis beyond the date in question. 
 
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 inpatient mental health care have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient mental health care provided from December 16, 2019, to 
December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior resin-based composite provided on September 
8, 2020. 
 
You asked the Plan to pay for the posterior resin-based composite. You say that you would like this service 
covered. The Plan denied your request. The Plan says the benefits for this service have been satisfied and the 
frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, restorations (fillings) and are limited to 
one procedure per calendar year. The record shows that you received an anterior resin-based composite on 
September 8, 2020, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does 
not have to pay for the posterior resin-based composite provided on September 8, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Foundation One genetic testing provided on July 29, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that this is FDA-approved as a companion diagnostic 
for patients with non-small cell lung cancer, melanoma, colorectal cancer, ovarian cancer or breast cancer to 
identify patients who may benefit from treatment with one of 21 target therapies in accordance with FDA-
approved therapeutic product labeling. F1CDx results are provided to the treating physician for management of 
the patient using a report template  that specifies treatment options. The Plan denied your request. The Plan 
says that the records submitted do not indicate the enrollee has been diagnosed with a specific type of cancer or 
that more  than five tumor markers meet criteria for testing, therefore this request is considered not medically 
necessary. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found advanced biliary cancers carry a poor prognosis. Standard therapies are largely for palliation of 
symptoms and not for definitive therapy or regression of disease. Molecular profiling/next generation 
sequencing including MSI testing are considered a standard of care for highly lethal cancers such as 
cholangiocarcinomas and use is supported by the NCCN Guidelines: for patients with advanced disease, 
providers may wish to consider molecular profiling to determine eligibility for clinical trials of new molecular 
targeted agents (ie for agents targeting mutated versions of IDH1, IDH2, FGF, and KRAS, among others). This 
patient has at least nodal involvement by a biliary cancer. The service is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the Foundation One genetic testing provided on July 29, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo custom fabricated abutments and two implant supported porcelain/ceramic crowns.You asked the Plan to pre-approvethe custom fabricated abutments and implant supported crowns. You say that these services should be approved because they are covered, and your allowance has not been met.The Plan denied your request. The Plan says these services are notcovered.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-approvetwo custom fabricated abutments and two implant supported porcelain/ceramic crowns.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement hand prosthesis (L7499). 
 
You asked the Plan to pre-approve the prosthesis. You say that the replacement prosthesis is medically 
necessary. The Plan denied your request. The Plan says that insufficient records were provided to support the 
request. 
 
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 the prosthesis. Our reviewer says that 
the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found 
there are sufficient records to support that the replacement prosthesis is medically necessary. The records 
document the amputation, the need for the prosthesis, and the enrollee's daily activities. The enrollee's current 
plastic prosthesis is broken and insufficient for his daily activities. The enrollee's use of tools in his daily 
activities with an insufficiently sturdy prosthesis puts him at risk for further injury. The enrollee's prosthetist 
appropriately recommends that L7499 be used. 
 
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 prosthesis have been met. Therefore, we decided that the Plan has to pre-
approve a replacement hand prosthesis (L7499).  
 
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 copayments for psychotherapy visits. 
 
You asked the Plan to waive the copayments for the therapy visits. You say that you have never been charged a 
copayment for therapy visits before. The Plan denied your request. The Plan says the correct copayment 
amounts were 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 $35 
copayment for outpatient mental health care.  
 
You have been asked to pay a $35 copayment for each therapy visit. These therapy 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 copayments for 
psychotherapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) and bitewing x-rays 
(D0274) provided on October 1, 2020. 
 
You asked the Plan to pay for the preventive procedure and bitewing x-rays. You say that you would like this 
claim reprocessed for payment. The Plan denied your request. The Plan says the preventive procedure is not a 
covered benefit. The Plan also says that the frequency limit for the bitewing x-rays had been exceeded. 
 
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 unspecified preventive procedure 
(D1999) is not among those covered under this benefit. The contract also clearly states that bitewing x-rays 
(D0274) are limited to one procedure per plan year. The record shows that you received bitewing x-rays 
(D0274) on March 10, 2020, and your bitewing x-rays (D0274) benefit had been exhausted. Therefore, we 
decided that the Plan does not have to pay for the preventive procedure (D1999) and bitewing x-rays (D0274) 
provided on October 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic ultrasound (97035) therapeutic 
activity (97110) massage therapy (97140) provided June 10, 2020 to July 20, 2020. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that you were told that 
the therapy services would be $10 per visit and since you were told $10 that's what you should pay not $40. 
You're more than happy to pay $120 but cannot afford $480. 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 $40 
copayment for physical therapy provided in an outpatient hospital.  
 
You have been asked to pay $40 copayment for the physical therapy services. The physical therapy services 
fall within the Outpatient rehabilitation 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 therapeutic ultrasound (97035) therapeutic activity (97110) massage therapy (97140) provided 
June 10, 2020 to July 20, 2020.