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

We decided that the Plan does not have to waive the copayment for the office visit provided on May 18, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you went for an annual wellness 
visit. You say that this should be covered. The Plan denied your request. The Plan says the copayment 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 $10 
copayment per visit for an in-network PCP.  
 
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the 
visit was a follow-up for chronic disease management. 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 office visit provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
your lab performed all tests that were ordered by the referring physician. The Plan denied your request. The 
Plan says utilization of network providers is required when possible and available. 
 
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 29, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 30, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you 
are required to get this testing every two weeks for your employment. The Plan denied your request. The Plan 
says these services are not covered per your EOC. 
 
The Plan must follow Medicare rules. Medicare rules say that examinations required by insurance companies, 
business establishments, government agencies, or other third parties are excluded from coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the record indicates that these services 
were for employment purposes. Therefore, we decided that the Plan does not have to pay for laboratory 
services provided on August 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that you believe this is the next step in 
treatment since injections have not helped. The Plan denied your request. The Plan says there is not sufficient 
support for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a surgical tissue transfer (14040), an 
electrolyte panel (80051), and a creatinine assay (82565) received from February 13 to February 15, 2020. 
 
You asked the Plan to waive the copayments for a surgical tissue transfer, an electrolyte panel, and a creatinine 
assay. You say that you were told the procedures/services were covered. The Plan denied your request. The 
Plan says the correct copayments 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 $350 
copayment for Medicare-covered surgery provided to you at an outpatient hospital and a $10 copayment for 
Medicare-covered lab services.  
 
You have been asked to pay a $350 copayment for a surgical tissue transfer as well as a $10 copayment each 
for an electrolyte panel and a creatinine assay. A surgical tissue transfer falls within the "Outpatient Surgery 
and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 
benefit category. An electrolyte panel and a creatinine assay 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 copayments for a 
surgical tissue transfer (14040), an electrolyte panel (80051), and a creatinine assay (82565) received from 
February 13 to February 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scan, abdomen and pelvis; with contrast 
material(s) (CPT Code 74177). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your 
request. The Plan says there is no supporting documentation for repeat imaging at this time without significant 
changes in the patient's medical condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our physician reviewer 
found based on the medical records provided there is no documentation that a follow up computed tomography 
(CT) scan, abdomen and pelvis; with contrast material(s) (CPT Code 74177) is medically reasonable and 
necessary as there is no documentation the enrollee has had a clinical follow-up after the scan of November 23, 
2020. There is no report of any new or persistent symptoms or examination or laboratory findings which meet 
Medicare National Coverage Determination criteria for a CT scan. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT scan, abdomen and pelvis; with contrast material(s) (CPT Code 74177).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diagnostic testing provided by a 
participating provider on July 7, 2020. 
 
You asked the Plan to waive the coinsurance for a PET scan. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 15% 
coinsurance for outpatient diagnostic tests.  
 
You have been asked to pay less than a 15% coinsurance of the allowed amount for a PET scan. The allowed 
amount is $2,753.13. The total amount you are being asked to pay is $406.73 which is less than your 15% 
coinsurance amount of $412.97 ($2,753.13 x 15% = $412.97). A PET scan falls within the outpatient 
diagnostic tests 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 diagnostic testing 
provided by a participating provider on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse some of your expenses for the biological materials to aid 
in soft and osseous tissue regeneration (D4265), the interim partial denture (D5821), 2 surgical extractions 
(D7210), and 2 bone replacement graft for preservation of alveolar ridge (D7953) provided on April 22, 2020. 
 
You asked the Plan to reimburse some of your expenses for the dental services. You say that your teeth broke. 
You say that there were no dentists available due to Covid-19. You also say that the services you received were 
an emergency. The Plan denied your request. The Plan says the provider in this case is not a network provider. 
The Plan also says that services you receive out of network are not covered. 
 
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 and dentures are listed as a covered 
item, dental items and services that you receive out of network are not covered. Additionally, the biological 
materials, surgical extractions and bone grafts are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to reimburse some of your expenses for the biological materials to aid in 
soft and osseous tissue regeneration (D4265), the interim partial denture (D5821), 2 surgical extractions 
(D7210), and 2 bone replacement graft for preservation of alveolar ridge (D7953) provided on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, post stabilization care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from 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 did not pre-approve the 
physician?s services. 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 physician's services provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT thorax provided. 
 
You asked the Plan to pay for the CT thorax. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says you submitted the claim with the wrong revenue code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate revenue code. 
 
We find that revenue code 0352 is incorrect. Based on this information, we decided that Medicare rules for 
coverage of the CT thorax have not been met. Therefore, we decided that the Plan does not have to pay for the 
CT thorax provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services rendered on March 31, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that in the event that no Kt/V reading was performed 
providers must report the D5 with a value of 9.99.  
 
We looked at the file and Medicare rules. The file shows that procedure code 90999 was not billed with the 
required D5 value of 9.99. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services 
rendered on March 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT Code 63650). 
 
You asked the Plan to pre-approve the services. You say that the pain management services will improve the 
member's symptoms. The Plan denied your request. The Plan says the Medicare criteria have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The documentation submitted did 
not include neurosurgical evaluation or psychological screening. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement (11042) provided on January 11, 2019. 
 
You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the member's name is missing from the 
procedure note. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the debridement have not been met. Specifically, the record does not include the member's name to 
verify the services billed. Therefore, we decided that the Plan does not have to pay for debridement (11042) 
provided on January 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 30, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 physician's services provided on June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided by a 
participating provider on March 11, 2020, to March 26, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were only supposed to 
stay for 3 days. 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 $250 
copayment per day for days 1-7. There is a $0 copayment for days 8-90 per admission for inpatient hospital 
care.  
 
You have been asked to pay less than a $250 copayment per day for days 1-7. There is a $0 copayment for days 
8-90 per admission for inpatient hospital stay. The total amount you are being asked to pay is $1,500 ($250 x 6 
days = $1,500) which is less than your total copayment amount of $1,750 ($250 x 7 days = $1,750). Inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay provided by a participating provider on March 11, 2020, to March 26, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that the evidence supports that this would 
be medically necessary. The Plan denied your request. The Plan says there is not sufficient support in the 
literature for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on May 21, 2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says the Plan requires utilization of network providers when possible and available, and 
requires authorization for certain services. No medical necessity for an out-of-network provider, such as an 
urgent or emergency situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services.  
 
 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical 
services provided on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on July 22, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were not 
informed that you would owe such a high copayment. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug injection on July 22, 2020. The allowed amount is $1,320 and 20% of 
that is $264.  
 
You have been asked to pay the total coinsurance amount of $264 for a Medicare Part B drug injection. A 
Medicare Part B drug injection 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 coinsurance for a Medicare Part B drug injection provided on July 22, 2020.