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

 
We decided that the Plan does not have to pay for a vitamin assay screening provided on January 8, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be paid by the plan. The Plan 
denied your request. The Plan says this type of screening is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. The rules 
specifically state vitamin assay screenings are not covered. The test at issue in this appeal was requested solely 
for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for a vitamin assay screening provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization (93458, 92920, 92928). You say that your 
cardiologist needs to diagnose you as soon as possible. The Plan denied your request. The Plan says that 
cardiac catheterization is not medically necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve left heart catheterization (93458, 92920, 
92928). Our reviewer says that the requested services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee meets published criteria for an invasive cardiac evaluation 
making the procedure medically necessary and reasonable for the treatment of the enrollee's condition based on 
the CMS coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization (93458, 92920, 92928) have been met. Therefore, we 
decided that the Plan has to pre-approve left heart catheterization.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment outpatient hospital services (93458, A9270, 
J2250, J3010) provided June 14, 2020 to June 17, 2020. 
 
You asked the Plan to waive the copayment the outpatient hospital services. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $250 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $250 copayment for the 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 outpatient hospital services (93458, A9270, J2250, J3010) provided June 14, 2020 to 
June 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the head or brain, x-ray exam of the neck spine, x-
ray of the shoulder, and ED visit provided on October 14, 2019. 
 
You asked the Plan to pay for the CT of the head or brain, x-rays, and ED visit. You say that this claim has not 
been paid in full or under the terms of the contract for the services provided to the enrollee. The Plan denied 
your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the CT of the head or brain, x-ray exam of the neck spine, x-
ray of the shoulder, and ED visit provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 16, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on June 23, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that another CT scan was ordered to 
follow up. You say that the second CT scan wasn't necessary, so you want the cost reduced. 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 $150 
copayment for each Medicare-covered advanced radiology service.  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. The records show that the CT scan was 
performed. 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 CT scan provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) provided on January 
27, 2020. 
 
You asked the Plan to reimburse you for the periapical x-ray. You say that the services you received are 
covered per your plan. You say that you called the dental office to ask why the services were not covered. You 
also say that you were advised that your plan did not have dental coverage. The Plan denied your request. The 
Plan says periapical x-rays are not listed as a covered service. 
 
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 periapical x-ray is not among those 
covered under this benefit, per the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
reimburse you for the periapical x-ray (D0220) provided on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT Scan (72125) provided on February 19, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 72125 is computed tomography, cervical spine; without 
contrast material  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the CT Scan. Our reviewer says that CPT code 72125 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found there is no documentation to 
support a procedure performed on the cervical spine. 
 
We looked at this coder'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 pay for the CT Scan (72125) provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided to the enrollee on May 23, 2019 
and billed under codes 80048, 85027 and P9604. 
 
You asked the Plan to pay for codes 80048, 85027 and P9604. We note the Plan paid for code G0471. You say 
that this claim should be paid. The Plan denied your request. The Plan says this claim could not be paid in full 
due to issues with the POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed 
due to issues with the POS code.   Medicare rules for coverage of this service were not met. Therefore, we 
decided that the Plan does not have to pay for testing services provided to the enrollee on May 23, 2019 and 
billed under codes 80048, 85027 and P9604.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture provided on February 14, 2020. 
 
You asked the Plan to pay for the maxillary partial denture. The Plan denied your request. The Plan says the 
maximum allowed for a replacement of an existing full/partial maxillary denture has 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, dentures are limited to 1 complete or 
partial denture every 5 years. The record shows that you received a fixed bridge on August 16, 2019, which the 
Plan paid for as an upper partial denture, and your maxillary denture benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the maxillary partial denture provided on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mastectomy bras (without integrated breast prosthesis) 
purchased June 7, 2019. 
 
You asked the Plan to pay for mastectomy bras. You say that Medicare used to cover these supplies and you 
were told by the provider that they are no longer covered. The Plan denied your request. The Plan says this type 
of garment is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that personal garments are not covered.  
While this item may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. 
Therefore, we decided that the Plan does not have to pay for a mastectomy bras (without integrated breast 
prosthesis) purchased June 7, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 17, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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. 
 
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 
laboratory 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 laboratory services provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on 
July 24, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you received a basic adult cleaning 
and not periodontal maintenance care. You say that the services you received on the date of service should all 
be covered at 100%. The Plan denied your request. The Plan says the claim was processed correctly. The Plan 
also says there is no contractual obligation to adjust, pay, or reimburse members for cost shares or covered 
services that are assessed appropriately. 
 
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, there is a 50% coinsurance for dental 
services that you receive up to the $1,250 annual dental benefit maximum. The records shows that the Plan 
confirmed with your dental provider that the service you received on this date of service was periodontal 
maintenance. Additionally, coinsurance is a contractual obligation that you agreed to when you signed up for 
the Plan. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance 
(D4910) provided on July 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot get out of bed on your own. The Plan 
denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to 
daily therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our physician reviewer found 
that you are having weakness and trouble walking. You are living at home after a discharge from skilled 
nursing. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs 
do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network skilled services provided to the enrollee on 
October 10, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network skilled 
services provided to the enrollee on October 10, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network outpatient mental health services provided to 
the enrollee on February 3, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have a referral for out of network care.  
 
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 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 out of network outpatient 
mental health services provided to the enrollee on February 3, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on December 23, 
2019. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were put in a waiting room not 
an exam room. You say that your ear was irrigated, and you were discharged. 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 $90 
copayment per visit for Medicare-covered emergency room visits. 
 
You have been asked to pay a $90 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 on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 30, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the phone call only lasted a few 
minutes and you feel that you should not be charged for it. 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 $40 
copayment for specialist visits.  
 
The medical records show that you had a specialist visit on July 30, 2020. Therefore, you are responsible to pay 
the $40 copayment.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctors 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 a specialist visit provided on July 30, 2020.
Appeal type: Practitioner Services
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 May 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 May 22, 2020.