Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasounds provided on May 27, 2020. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you were informed the 
procedures were coded incorrectly. You say that you were informed the procedures should have a $0 
copayment. The Plan denied your request. The Plan says the copayments 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility.  
 
You have been asked to pay a $110 copayment for each ultrasound. The total amount you owe is $220 
($110/ultrasound x 2 ultrasounds = $220). The ultrasounds 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 
the ultrasounds provided on May 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on June 30, 2020. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you thought that you would only 
owe 20% coinsurance. 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 $160 
copayment for ultrasounds.  
 
You have been asked to pay a $160 copayment for a duplex scan. A duplex scan falls 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 a duplex scan provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has sickle cell disease and 
has several crises each year. She has low back pain without radiation. The records do not support an evidence-
based indication for the SCS trial. She has not had intra-thecal medication therapy. The services are not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on February 11, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the original claim was not submitted within 365 days from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until October 22, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for office visit services provided to the enrollee on February 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical components (TC) of the nerve conduction 
studies, electromyography, somatosensory testing, and electroencephalography provided during an inpatient 
surgery on May 20, 2020. 
 
You asked the Plan to pay for the TC of the neuromonitoring services. You say that it is felt that payment 
should be made for these services. The Plan denied your request. The Plan says Medicare does not make 
separate payment for these services when provided to an inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that non-physician services are included in payment 
to the facility and the facility must furnish these services either directly or through arrangements. 
 
The TC of diagnostic testing is not considered a physician service. The Physician Fee Schedule indicates that 
the TC does not include physician work. As such, payment for these service may not be made separately for a 
hospital inpatient. Therefore, we decided that the Plan does not have to pay for the technical components (TC) 
of the nerve conduction studies, electromyography, somatosensory testing, and electroencephalography 
provided during an inpatient surgery on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 dental extractions (D7140 x 4) performed on July 21, 2020. 
 
You asked the Plan to pay for 4 dental extractions. You say that these services were necessary. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
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. 
 
We looked at the case file and Medicare rules. We found that 4 dental extractions were provided in excess of 
the annual limit for this service on the Plan?s dental benefit. Based on this information, we decided that the 
Plan's rules for coverage of 4 dental extractions have not been met. Therefore, we decided that the Plan does 
not have to pay for 4 dental extractions (D7140 x 4) performed on July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab/Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug for treatment of ovarian cancer that lacks MSI, MMR deficiency, 
and high tumor mutational burden is not FDA approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found this is denied per the 
compendia and literature, as MSS and TMb are low. PDL1+ cannot be used as a basis of approval. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab/Keytruda for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an X-ray provided on July 3, 2020. 
 
You asked the Plan to waive the deductible for an X-ray. You say that you feel that the charges are excessive. 
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 $300 deductible for outpatient basic radiological services.  
 
You received an X-ray on July 3, 2020. The record shows that you had paid $0 toward the $300 deductible 
prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $8.28.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
basic radiological services. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $300 deductible for outpatient basic radiological services. This cost sharing is a contractual obligation that 
had not been met at the time an X-ray was received on July 3, 2020. Therefore, we decided that the Plan does 
not have to waive the deductible for an X-ray provided on July 3, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided from June 30, 2020, 
through July 1, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that there was no clear diagnosis for the 
way you presented to the hospital. You say that you want the claim reviewed. 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 $100 
copayment for each emergency room visit. 
 
You have been asked to pay a $100 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided from June 30, 2020, through July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services should be covered as in-network. 
The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan says that 
neither your lab, nor the ordering provider is a Plan provider.  In addition, the Plan confirmed that you did not 
have authorization from the Plan or from a Plan provider to render these services. 
 
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. 
 
You are not a network provider with the Plan. The Plan did not pre-approve the lab services at issue. We found 
no exception that would require the Plan to pay for these lab services. Therefore, we decided that the Plan does 
not have to pay for the lab services provided on January 9, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac device evaluation provided on May 28, 2020. 
 
You asked the Plan to waive the copayment for the cardiac device evaluation. You say that you didn't see a doctor, just a 
technician. You say that you received a pacer check for five years with no charge. 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 $15 copayment 
for provider and professional services at an in-network specialist's office.
 
You have been asked to pay a $15 copayment for the cardiac device evaluation. The cardiac device evaluation 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 the cardiac device evaluation provided on May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT Code(s) 22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 services. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Superion interspinous spacer (CPT Code(s) 22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a passive hand prosthesis. 
 
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested prosthesis cannot be covered as the incorrect code was used. 
 
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 prosthesis. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the treating medical practitioner progress notes do not indicate a detailed upper extremity 
neuromuscular exam or indication that this patient will use the requested prosthetic device for activities of daily 
living. There are no detailed notes from the treating medical practitioner on how the enrollee's activities of 
daily living are affected with and without the device. There is no documentation of the enrollee's specific 
functional needs for this device.  It is not clear from the treating medical practitioner's medical progress notes 
that this requested prosthesis is appropriate to the enrollee's medical needs and condition; therefore, this request 
for the custom silicone passive prosthesis is not 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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a passive hand prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 5, 2020. 
 
You asked the Plan to pay for the dental service. You say that the claim was denied because your dentist is no 
longer in network. You say that claim should be paid for preventive health purposes. The Plan denied your 
request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot 
be made to providers that have opted out of Medicare. The Plan also says that a notification letter was sent out 
on February 6, 2020 advising that services rendered by the provider in this case would be paid starting 15 days 
after the postmark date on the letter. 
 
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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ultrasound provided on September 11, 
2020. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that you were billed for a diagnostic 
service instead of a preventive screening. The Plan denied your request. The Plan says the deductible for the 
hospital claim applied correctly. The Plan also says that the deductible for the physician claim was waived. 
 
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 your deductible is $750. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost of your covered services. Diagnostic imaging services are not excluded from the 
deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $750 deductible applies to diagnostic imaging. The ultrasound is considered 
a diagnostic imaging service. 
 
 
 
 
 
 
This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on 
September 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the 
ultrasound provided on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 
23, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you waited for two hours 
before being transferred to another hospital. 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 $250 for 
each one-way Medicare-covered ambulance transport. 
 
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance 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 
the ambulance transport provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on June 22, 2020. 
 
You asked the Plan to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, 
and including elevation of mucoperiosteal flap if indicated. You say that the service should be covered. The 
Plan denied your request. The Plan says that the service is not a covered benefit. 
 
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. The Plan covers extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated have been met. Specifically, this service is listed as a covered 
benefit in the Plan?s Dental Directory. Therefore, we decided that the Plan has to pay for extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) provided on June 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for root canal therapy (D3330) received on July 30, 2020. 
 
You asked the Plan to pay for root canal therapy. You say that you were misinformed when you called 
regarding coverage for root canal therapy. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
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 root canal 
therapy (D3330) received on July 30, 2020.