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

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services received on 
May 28, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you wish to dispute 
this copayment. 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 $475 
copayment for Medicare-covered outpatient hospital services.  
 
You have been asked to pay a $475 copayment for outpatient hospital services. 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 outpatient hospital services received on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0140), the periapical x-ray (D0220), the 
filling (D2393), and the miscellaneous dental service (D9999) provided on April 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist was closed due to Covid-
19. You say that you felt the services could not wait until your dentist was reopened. You also say that you 
called around trying to find a participating dentist with no luck. The Plan denied your request. The Plan says 
payment cannot be made for services that you receive from a dentist that 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 oral exam (D0140), the periapical x-ray (D0220), the filling (D2393), and the miscellaneous dental service 
(D9999) provided on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on September 25, 
2019. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that your brother had the same 
procedure and was not charged 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 a $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amalgam for tooth #'s 3, 4 and 5 provided on June 11, 2020. 
 
You asked the Plan to pay for amalgam. You say that the Plan was called prior to receiving dental care. You 
say that you are appealing the decision to not cover the dental work. The Plan denied your request. The Plan 
says the service is 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for amalgam 
for tooth #'s 3, 4 and 5 provided on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81201, 81210, 81272, 
81293, 81310, 81311, 81314, 81321) provided on June 9, 2020. 
 
You asked the Plan to pay for Guardant360 testing. You say that this is medically indicated. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. To report a CGP service, test providers should 
use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the test. 
 
We find that CPT codes 81120, 81121, 81201, 81210, 81272, 81293, 81310, 81311, 81314, 81321 are not 
supported in the medical record. Specifically, the record shows these codes were used to report a CGP service, 
which should be billed with CPT 81479. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360 testing (81120, 81121, 81201, 81210, 81272, 81293, 81310, 81311, 81314, 81321) provided 
on June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee can safely receive necessary care in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the current acute care facility. At the time the enrollee is considered medically 
stable by the treating team the enrollee may be a candidate for care at a less intense level. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on June 14, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for cochlear implant batteries. You say that reimbursement has always been applied. 
You say that this year should be the same. The Plan denied your request. The Plan says prior authorization was 
not obtained. The Plan says that this provided is out-of-network. 
 
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 durable medical equipment provided on June 14, 
2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 2, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you cannot afford 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig Autoinjector. 
 
You asked the Plan to pre-approve Aimovig Autoinjector. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the Aimovig Autoinjector is not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aimovig Autoinjector.  
 
Benefits for Aimovig Autoinjector may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on March 9, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services 
were billed incorrectly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a contract provider. The file does not show that the plan 
provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the plan. The Medicare coverage criteria referenced by the Plan is not applicable for 
the jurisdiction in question. Therefore, we decided that the Plan has to pay for the lab services provided on 
March 9, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux (J9055) and Irinotecan (J9206). 
 
You asked the Plan to pre-approve Erbitux and Irinotecan. You say that these services are medically necessary 
based on the enrollee's medical condition. The Plan denied your request. The Plan says Medicare Advantage 
plans can't require prior authorization review of Part B services related to clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
 
 
 
 
 
 
 
In this case, you asked the Plan to pre-approve Erbitux and Irinotecan as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve Erbitux (J9055) and Irinotecan (J9206).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on May 20, 2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges 
because you were not informed of them ahead of time. 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 $15 
copayment for lab services.  
 
You have been asked to pay a $15 copayment for lab services. Lab 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 lab services provided on May 20, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an absolute quantitation of myocardial blood flow (AQMBF) 
positron emission tomography (PET) test. 
 
You asked the Plan to pre-approve the AQMBF PET test. You say that , given the new SPECT with ongoing 
chest pain, a PET stress test is needed for further evaluation. The Plan denied your request. The Plan says that 
the requested service has not been shown to be safe and effective and is considered investigational and 
experimental. The Plan says that the clinical value of the service has not been established and, therefore, is not 
indicated at this time. 
 
The Plan follows Medicare rules. Medicare rules say that the PET scan, whether at rest alone or rest with stress, 
is used following a SPECT that was found to be inconclusive. In these cases, the PET scan must be considered 
necessary in order to determine what medical or surgical intervention is required to treat the patient. 
 
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 AQMBF PET test. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found the enrollee has anginal type 
chest discomfort and an inconclusive stress MPI scan with possible anterior wall ischemia. She meets Medicare 
NCD coverage criteria for Rubidium 82 PET Perfusion imaging of the heart for consideration of further 
medical or surgical treatment of coronary artery 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 the AQMBF PET test have been met. Therefore, we decided that the Plan has to 
pre-approve an absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography (PET) 
test.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of head or brain and 
ultrasound scanning of blood flow (70450, 93880) provided on April 17, 2020, by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the CT scan and ultrasound scan of blood flow. You say that you were not 
provided with the enrollee's insurance information. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 computed tomography (CT) of head or brain 
and ultrasound scanning of blood flow (70450, 93880) provided on April 17, 2020, by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP filters (A7038) provided on August 16, 2019. 
 
You asked the Plan to pay for the CPAP filters. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not include 
a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record does not 
include a physician order for the billed date of service. Of note, the physician order included is dated May 2, 
2020.  The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for CPAP filters (A7038) provided on 
August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the home visit (99349). You say that you would like reconsideration because 
authorization is no longer needed for telehealth services. The Plan denied your request. The Plan says these 
services were not referred by a network provider, urgent, emergent or 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 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 3, 2020 by 
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided May 21, 2020 through May 
22, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that no prior authorization was obtained for the non-participating 
provider. The services provided by the nonparticipating facility, are denied coverage under the terms of the 
member's group contract, since the services can be provided by a participating facility. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided May 21, 2020 through May 22, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this should be covered. The Plan denied 
your request. The Plan says the benefit is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.