Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three posterior resin-based composites of one surface and 
three resin-based composites of two surfaces provided from November 13, 2019 to December 10, 2019. 
 
You asked the Plan to pay for the resin-based composites. You say that it is imperative to try saving your 
remaining teeth so that you can eat. You also say that you are in pain, and cannot afford to pay for these 
services. The Plan denied your request. The Plan says the benefits for these services had been satisfied and the 
frequency limitation 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, restorations are limited to two 
procedures per calendar year. The record shows that you received two resin-based composites on October 29, 
2019, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to 
pay for the three posterior resin-based composites of one surface and three resin-based composites of two 
surfaces provided from November 13, 2019 to December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first 30-74 minutes (99291) critical care each 
additional 30 minutes (99292) provided December 4, 2019 to December 10, 2019. 
 
You asked the Plan to pay for the critical care services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 and 99292 is critical care, first 30-74 minutes and 
critical care each additional 30 minutes. 
 
We find that CPT code 99291 and 99292 is not supported in the medical record. Specifically, the 
documentation submitted do not include a critical care progress note for the billed dates of service. In addition, 
there is a daily progress note submitted for the same date and an ENM code is billed which has been 
reimbursed. Based on this information, we decided that Medicare rules for coverage of the critical care services 
have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first 30-74 
minutes (99291) critical care each additional 30 minutes (99292) provided December 4, 2019 to December 10, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 2, 
2019. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you did not receive a surgical 
procedure and disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 specialist services.  
 
You have been asked to pay a $35 copayment for arthrocentesis. Arthrocentesis falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for arthrocentesis provided on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for portable X-Ray services. You say that you do not have ample time to verify 
eligibility and process authorization. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because this provider is out-of-network with the Plan and the ordering provider is also 
out-of-network with the Plan. 
 
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 February 4, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided May 20, 2019 to 
May 30, 2019. 
 
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization inpatient care. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found the treating 
physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for 
transfer. 
 
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 post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for post-stabilization inpatient care provided May 20, 2019 to May 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on March 23, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you should only have to pay $95 and not 
$190. The Plan denied your request. The Plan says the correct copayments have 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 $95 
copayment for outpatient diagnostic tests/in-network/diagnostic radiology.  
 
You have been asked to pay a $95 copayment for an MRI. The total amount you are being asked to pay is $190 
($95 x 2 MRIs = $190).  Two separate MRIs were provided; therefore, two separate copayments have been 
applied. An MRI falls within the outpatient diagnostic tests/in-network/diagnostic radiology 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 MRI provided by a participating provider on March 23, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ultrasounds provided on January 16, 2020. 
 
You asked the Plan to waive the deductible for ultrasounds. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
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 $500 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received ultrasounds on January 16, 2020. The record shows that you had paid $0 toward the $500 
deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of 
$232.70.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time ultrasounds were 
received on January 16, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
ultrasounds provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special stained specimen slides (88312) provided on January 
28, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for special stained specimen slides. You say that code 88312 is incorrectly cross 
walked with code 88313. The Plan denied your request. The Plan says services were provided by out-of-
network providers without 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 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 special stained specimen slides (88312) provided 
on January 28, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on 
April 8, 2020 and May 5, 2020. 
 
You asked the Plan to waive the copayments for outpatient mental health care. You say that you disagree with 
the charges because you qualify for Medicaid assistance. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $30 
copayment for outpatient mental health care.  
 
You received outpatient mental health care on April 8, 2020. Therefore, you are responsible to pay the $30 
copayment.  
 
You received outpatient mental health care on May 5, 2020. Therefore, you are responsible to pay the $30 
copayment. 
 
The total amount you owe is: $60.  
 
You have been asked to pay the total copayment amount of $60 for outpatient mental health care. Outpatient 
mental health care falls 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 outpatient mental health care provided on April 8, 2020 and May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the medical records support the lab services. The 
Plan denied your request. The Plan says the service require prior authorization, which 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 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 lab services provided on April 6, 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 eyewear purchased on June 2, 2020. 
 
You asked the Plan to pay for the eyewear. You say that you want the Plan to pay more. The Plan denied your 
request. The Plan says you exhausted your maximum benefit allowance. 
 
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.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Review of the file show that you purchased eyewear on June 2, 
2020. The Plan paid $200 for the eyewear and you a responsible for the remainder. Your EOC states, "covered 
services include a $200 allowance for supplemental eyewear every year. Members are responsible for all costs 
over and above the allowance amount." Therefore, we decided that the Plan does not have to pay for the 
eyewear purchased on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 11, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's cancer. The Plan denied your request. The Plan says there is 
a more appropriate code to describe the services provided. 
 
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 testing is not supported in the documentation provided. Specifically, the claim does not show 
that the coding and billing guidance has been followed. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a greater occipital nerve injection and a trigger point injection. 
 
You asked the Plan to pre-approve a greater occipital nerve injection and a trigger point injection. You say that 
the requested greater occipital nerve injection and trigger point injection are medically necessary. The Plan 
denied your request. The Plan says that the requested greater occipital nerve injection and trigger point 
injection are 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 pre-approve a greater occipital nerve injection and a 
trigger point injection. Our reviewer says that the requested greater occipital nerve injection and trigger point 
injection are medically necessary. Our physician reviewer found the enrollee has a diagnosis of Chronic 
migraine without aura, intractable, without status migrainosus. The enrollee presented with intractable chronic 
migraine headaches and cervicalgia. Cranial Greater/Lesser occipital nerve block and auriculo-temporal, 
supraorbital, para-cervical, and trapezius trigger point injections were performed on 7/6/20. 
 
There is evidence that greater occipital nerve injections are a medically reasonable and necessary option for 
patients with severe and prolonged migraine headaches that have been refractory to standard migraine 
treatments. Peripheral nerve blocks have been shown to provide clinical improvement in patients with common 
headache disorders. The requested treatment is medically reasonable and necessary in this case. 
 
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 greater occipital nerve injection and a trigger point injection have been met. 
Therefore, we decided that the Plan has to pre-approve a greater occipital nerve injection and a trigger point 
injection.  
 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ultrasounds provided on January 20, 2020. 
 
You asked the Plan to waive the deductible for ultrasounds. You say that you have never had to pay for 
ultrasounds in the past and disagree with the charges. The Plan denied your request. The Plan says the claims 
were processed correctly, and you are being charged the correct amount. 
 
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 $500 deductible for outpatient diagnostics. 
 
You received ultrasounds on January 20, 2020. The record shows that you had only paid $232.70 toward the 
$500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of 
$69.43.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible for outpatient diagnostics for outpatient diagnostic 
tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at 
the time ultrasounds were received on January 20, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for ultrasounds provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided by an out-of-
network provider on January 15, 2020. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you were told that this provider 
was in-network. You say that you were given misinformation. The Plan denied your request. The Plan says the 
correct coinsurance has been applied to the services that were provided. 
 
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 50% 
coinsurance for physician/practitioner services/out-of-network.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for an office visit. The total allowed 
amount is $107.33. The total amount you are being asked to pay is $53.66 ($107.33 x 50% = $53.66). An office 
visit falls within the physician/practitioner services/out-of-network 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 coinsurance for an office visit provided by an out-of-network provider on January 15, 2020.  
 
We note your complaint about being given misinformation about the provider being in-network. Your 
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on 
February 20, 2020 and March 17, 2020. 
 
You asked the Plan to waive the copayments for outpatient mental health care. You say that you disagree with 
the charges because you qualify for Medicaid assistance. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $30 
copayment for outpatient mental health care.  
 
You received outpatient mental health care on February 20, 2020. Therefore, you are responsible to pay the $30 
copayment.  
 
You received outpatient mental health care on March 17, 2020. Therefore, you are responsible to pay the $30 
copayment. 
 
The total amount you owe is: $60.  
 
You have been asked to pay the total copayment amount of $60 for outpatient mental health care. Outpatient 
mental health care falls 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 outpatient mental health care provided on February 20, 2020 and March 17, 2020.