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

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from a network provider and in most cases, care received from an out-of-network provider 
will not be covered, except for the following: emergency care or urgently needed service and needed medical 
care that Medicare requires our plan to cover and the providers in our network cannot provide this care 
(authorization is required). 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) for lung cancer 
screening rendered on October 9, 2019. 
 
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 exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that an LDCT for lung cancer screening is covered 
when specific criteria are met. The Plan contract says that for qualified individuals, a LDCT is covered every 
12 months. 
 
We looked at the file and Medicare rules. The file shows that you received an LDCT on March 5, 2019 for 
which the Plan approved and paid. The LDCT on October 9, 2019 was performed less than 12 months from the 
previously covered exam. Based on this information, we decided that Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the low dose 
computed tomography (LDCT) for lung cancer screening rendered on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and surgery injection services provided on
December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services and an outpatient surgery. You say that you would like this
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization
was not obtained. The Plan says that the referring provider is also 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 physician services and surgery injection services
provided on December 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 24, 2019. 
 
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 procedure code 81479 was billed with the -GZ modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claims billed with the -GZ modifier are 
automatically denied. 
 
We looked at the file and Medicare rules. The file shows that procedure code 81479 was billed with the -GZ 
modifier and will automatically deny, per Medicare rules. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on February 14,
2020.
You asked the Plan to waive the copayment for the duplex scan. You say that you should not be responsible for
an additional $50 copayment. The Plan denied your request. The Plan says you have been charged the correct
cost sharing 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 $50
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a $50 copayment for the duplex scan. The duplex scan falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the duplex scan is
considered a radiological procedure.
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 duplex scan provided on February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclophosphamide for the enrollee. 
 
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not 
covered under Part B. 
 
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 Cyclophosphamide for the 
enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 8, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that this service was medically necessary, and you did not 
realize that authorization would be required. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this provider is out-of-network with the Plan and authorization 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 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 October 8, 2019 
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 ultrasounds provided on March 11, 2020.
You asked the Plan to waive the copayment for ultrasounds. You say that you paid your $30 copayment. You
say that you were never told there would be additional copayments. 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 $125
copayment for outpatient diagnostic tests/radiological diagnostic service.
You have been asked to pay a total of $209.79 which is less than your copayment amount of $375 ($125 x 3
ultrasounds = $375) for ultrasounds. The correct copayments have been applied to the services that were
provided. Ultrasounds fall within the outpatient diagnostic tests/radiological diagnostic service 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 ultrasounds provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on March 11, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided on March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs provided on
February 4, 2020.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were told that any
medication you receive at your doctor's office were covered at no-charge. The Plan denied your request. The
Plan says you have been charged the correct cost sharing 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 chemotherapy drugs at an in-network specialist's office or outpatient hospital.
You have been asked to pay a total of $154.40 which is 20% of the allowed amount for the chemotherapy
drugs. The total allowed amount is $772.02. ($772.02 x 20% = $154.40). The chemotherapy drugs fall 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 the chemotherapy drugs provided on February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac gel.
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 self-administered drugs are not covered.
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 Diclofenac gel.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that 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 physician's services provided on March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Veltassa.
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 self-administered drugs are not covered.
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 Veltassa.
Benefits for these services 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve routine transportation services. You say that you need transportation 
because you have nobody that can assist with driving. The Plan denied your request. The Plan says that the 
denial of authorization for routine transportation is correct, because you have used all 24 one-way trips covered 
by the Plan's routine transportation benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage (EOC) 
for your contract with the plan. Without the EOC, we cannot determine the routine transportation benefits and 
benefit limits offered by the Plan. The Plan says that you have exhausted the 24 one-way trips covered by your 
routine transportation benefit, however the Plan has not shown that such a benefit limit exists. Furthermore, the 
Plan has not shown that you have already received 24 one-way routine transportation trips in 2020. Without 
this information, the Plan has not shown that its decision to deny routine transportation is correct or justified 
according to the Plan?s benefits. Therefore, we decided that the Plan has to pre-approve routine transportation 
services.  
 
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: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250).
You asked the Plan to pre-approve a CT scan of the thorax. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 a CT scan of the thorax. Our reviewer says that the services are medically necessary. Our physician reviewer found the interval increase in size of 3 mm of a ground glass pulmonary nodule is worrisome for malignancy as included in the radiologist's written report of the May 15, 2020 CT scan. Ground glass nodules are especially worrisome for lung cancer and the size of the nodule in question (1.9cm) together with interval increase in size merit close surveillance. A 3-4 month follow-up is very reasonable and indicated and should be approved. The other approach in this scenario would be a PET/CT due to the size of the nodule in question. CMS has recognized the utility of PET imaging to evaluate for malignancy and a nodule of 1.9 cm could be assessed if the next CT is equivocal. 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 CT scan of the thorax have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250).
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 pre-approve a colonoscopy to be provided at the out-of-network
facility.
You asked the Plan to pre-approve the colonoscopy. The Plan denied your request. The Plan says the member
does not have elective out-of-network benefits.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a
colonoscopy to be provided at the out-of-network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that a core buildup is necessary for the retention
of the crown. The Plan denied your request. The Plan says this 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 pre-approve a
core buildup, including any pins when required (D2950).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve PET scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is needed due to the colon cancer diagnosis. The Plan denied your request. The Plan says that there is no restaging or recurrence of cancer present.
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found since the repeat PET/CT scan is being requested to evaluate prior to planned surgical removal of a solitary metastatic lesion, CMS guidelines allow for such an exam prior to surgery to prove the lesion scheduled for removal is indeed still a solitary lesion. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve PET scan for the enrollee.
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 the two crowns and two core buildups, including any pins
when required provided on January 28, 2020.
You asked the Plan to pay for the crowns and core buildups. You say that these services were medically
necessary. The Plan denied your request. The Plan says you were reimbursed the full maximum amount of
$500.
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 Plan offers a $500 maximum
benefit every plan year. The record shows that you met the annual maximum benefit while processing this
claim on January 28, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that
the Plan does not have to pay for the two crowns and two core buildups, including any pins when required
provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you've been going to this doctor for 
years. The Plan denied your request. The Plan says there are in-network providers available for 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic services to be provided by an out of network (OON) provider.