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

 
We decided that the Plan does not have to pre-approve Praluent injections. 
 
You asked the Plan to pre-approve the Praluent injections. The Plan denied your request. The Plan says this 
drug is a self-administered drug and is not Part B 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 Praluent injections.  
 
Benefits for the Praluent injections 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: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a mammogram provided on January 31, 2020. 
 
You asked the Plan to waive the copayment for a mammogram. You say that this was a mammogram screening 
and you should not owe a copayment. The Plan denied your request. The Plan says that the claims were 
processed correctly and you are being charged the correct amount. 
 
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 medical records. Without medical records we cannot 
determine whether the mammogram was considered diagnostic or preventative. Therefore, we decided that the 
Plan has to waive the copayment for a mammogram provided on January 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 7,
2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges
because you were told by the provider that you only owed a $35 copayment but now you are being billed
additional 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 $100
copayment for diagnostic procedures and tests provided in an outpatient hospital facility.
You have been asked to pay the allowed amount of $96.42, which is less than the $100 copayment for an
ultrasound. An ultrasound 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 an ultrasound provided on
February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the dialysis treatments provided from 
January 3, 2020 to April 29, 2020. 
 
You asked the Plan to reduce the coinsurance for the dialysis treatments. You say that you cannot afford this 
bill. You say you were not notified about the change in coverage. 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% for 
Medicare-covered renal dialysis service.  
 
You have been asked to pay a total of $3,120 for the dialysis treatments. The dialysis treatments fall within the 
"Services related to treat kidney disease" benefit category. See chart below. 
 
Dates of Service Service Allowed 
Amount 
Coinsurance Number of 
Visits 
Member 
Liability 
January 3, 2020 to 
January 31, 2020 
Dialysis $300 20% 13 $780 
February 3, 2020 to 
February 28, 2020 
Dialysis $300 20% 12 $720 
March 2, 2020 to 
March 31, 2020 
Dialysis $300 20% 14 $840 
April 1, 2020 to 
April 29, 2020 
Dialysis $300 20% 13 $780 
Dates of Service Service Allowed 
Amount 
Coinsurance Number of 
Visits 
Member 
Liability 
Total     $3,120 
 
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 reduce the coinsurance for the dialysis treatments provided from January 3, 2020 to 
April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the respiratory flow volume loop (94375). You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of
network providers is required when possible and available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 10, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and care 
management services (99490) provided on October 15, 2019 by an out of network (OON) provider. 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and care management services (99490) provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON domiciliary or rest home visit and care management services. You say that the facility should have obtained authorization. The Plan denied your request. The Plan says these 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 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 domiciliary or rest home visit (99336) and care management services (99490) provided on October 15, 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 lab services (CPT 87633) provided on March 4, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCA A57579 provides a list of non-covered CPT codes. We looked at the file and Medicare rules. Per A57579, CPT code 87633 is a non-covered code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (CPT 87633) provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adhesive remover, wipes (A4456), skin barrier, wipe or swab 
(A5120), filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture 
exchange system (A7507) and housing and integrated adhesive, for use in a tracheostoma heat and moisture 
exchange system and/or with a tracheostoma valve (A7508) provided to the enrollee on December 13, 2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. 
 
Healthcare Common Procedure Coding System (HCPCS) code A7507 (180 Units) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, 
or proof of delivery. Therefore, the billed supply code cannot be verified.  It is noted that multiple attempts 
were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A7508 (180 Units) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, 
or proof of delivery. Therefore, the billed supply code cannot be verified.  It is noted that multiple attempts 
were made to contact the provider for additional information.  
 
Healthcare Common Procedure Coding System (HCPCS) code A4456 (150 Units) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, 
or proof of delivery. Therefore, the billed supply code cannot be verified.  It is noted that multiple attempts 
were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A5120 AU (150 Units) remains not supported. 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific 
supplies, or proof of delivery. Therefore, the billed supply code cannot be verified.  It is noted that multiple 
attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does 
not have to pay for adhesive remover, wipes (A4456), skin barrier, wipe or swab (A5120), filter holder and 
integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system (A7507) and 
housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a 
tracheostoma valve (A7508) provided to the enrollee on December 13, 2019.
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 is medically necessary. The Plan 
denied your request. The Plan says the available trips were 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 6 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that there has been provider-directed conservative 
treatment. The Plan denied your request. The Plan says the medical records submitted do not document a 
reason for ordering an MRI of the brain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found in this setting - in the 
absence of an indication within the medical records that the enrollee has a condition for which the requested 
study would be considered to be reasonable and necessary--this request would not meet Medicare criteria for 
coverage. The enrollee's symptoms were otherwise localized to her cervical spine. The enrollee had no signs, 
symptoms or complaints that would suggest a process necessitating imaging of her brain. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the brain for the enrollee.
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 you need to continue your physical therapy 
sessions that you attend twice per week. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. You are requesting additional trips beyond 
the 50 you are allotted by your contract. The 51st trip and beyond is not a covered benefit. You have six trips 
remaining. 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.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a panniculectomy (15830). 
 
You asked the Plan to pre-approve a panniculectomy. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
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 a panniculectomy. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted medical records show that you have complications including intertrigo, recurrent 
infection, and pain due to the excessive pannus. It is medically necessary and appropriate to excise it. The 
procedure is not being performed for your convenience and is not cosmetic in nature. Medical necessity and 
reasonableness are established and it is in accordance with the standard of care for the treatment of this 
condition. 
 
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 panniculectomy have been met. Therefore, we decided that the Plan has to 
pre-approve a panniculectomy (15830).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 12, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the prolonged evaluation and management service (99358). You say that you 
would like reconsideration because the services rendered were medically necessary. The Plan denied your 
request. The Plan says prior authorization for services with the non-contracted provider is absent. 
 
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 November 12, 
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the porcelain pontic (D6240) and the 
porcelain retainer crowns (D6750 x 2) provided on December 11, 2019. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have already 
received the yearly maximum benefit allowable for these services. 
 
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 the Plan?s rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, you previously received dental services on 
September 26, 2019 and October 21, 2019 that were paid for by the Plan in the amount of $750. Your request 
for payment exceeds the yearly maximum benefit allowable. Therefore, we decided that the Plan does not have 
to issue reimbursement for the porcelain pontic (D6240) and the porcelain retainer crowns (D6750 x 2) 
provided on December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on March 8, 2020 to March 16, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with
these charges. You say that it was due to a medication overdose caused by a skilled nursing facility. The Plan
denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125
copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $125 copayment per day for days 1-7. The total amount you are being asked to
pay is $875 ($125 x 7 days = $875). An inpatient hospital stay falls within the inpatient hospital care benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on March 8, 2020 to March 16, 2020.
We note your complaint about having to go to the hospital due to a medication overdose caused by a skilled
nursing facility. Your complaint is a grievance that must be answered by the health plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided 
February 22, 2020 to February 23, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $200 
copayment per day, for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $200 copayment ($200 x 1 day) for inpatient hospital care. 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 inpatient hospital care provided February 22, 2020 to  
February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the x-ray provided on February 16, 2020. 
 
You asked the Plan to waive the coinsurance for the x-ray. You say that the claim was processed incorrectly. 
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 per provider, per date of service for out-of-network routine radiology.  
 
You have been asked to pay $7.10 which is 20% of the allowed amount for the x-ray. The allowed amount is 
$35.52. ($35.52 x 20% = $7.10). The x-ray 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 coinsurance for the x-ray provided on 
February 16, 2020.