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

 
We decided that the Plan does not have to waive the coinsurance for a Botox injection (J0586) received on June 
29, 2020. 
 
You asked the Plan to waive the coinsurance for a Botox injection. You say that you were told you would have 
only a $5 copayment and 20% coinsurance. The Plan denied your request. The Plan says the correct 
coinsurance 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 20% 
coinsurance for Medicare-covered Part B drugs.  
 
You have been asked to pay $336.12, or 20% of the Plan-allowed amount of $1,680.60, for a Botox injection. 
A Botox injection falls 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 a Botox injection (J0586) received on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the established patient office or other 
outpatient visit (99214) provided on March 27, 2020. 
 
You asked the Plan to waive the copayment for the established patient office or other outpatient visit. You say 
that you would like the Plan to waive your required cost share. The Plan denied your request. The Plan says the 
services you received were rendered prior to the Plan's cost share waiver program. Therefore, the copayment 
applied correctly in this case. 
 
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 $150 yearly deductible for covered medical services.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category 
physician/practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $150 yearly deductible for your covered medical servies. This cost sharing is a contractual obligation 
that had not been met at the time the established patient office or other outpatient visit was received on March 
27, 2020. Therefore, we decided that the Plan does not have to waive the copayment for the established patient 
office or other outpatient visit (99214) provided on March 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergent ambulance transportation service (A0427) and 
the ambulance mileage (A0425) provided on November 13, 2019. 
 
You asked the Plan to pay 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 the ambulance transportation service is not a 
covered benefit by Medicare or the Plan as it was provided outside of the United States. 
 
The Plan must follow Medicare rules. Medicare rules say that services received outside of the United States are 
not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transportation services have not been met. Specifically, services received outside of 
the United States are not covered. Therefore, we decided that the Plan does not have to pay for the emergent 
ambulance transportation service (A0427) and the ambulance mileage (A0425) provided on November 13, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 4, 5, 10, and 12 
and pontics (D6245) for tooth #'s 6, 7, 8, 9, and 11. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. The Plan denied your request. The Plan 
says the documents failed to demonstrate a specific medical condition that would preclude the use of a 
removable partial denture. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the retainer 
crowns and pontics when the services are medically necessary and reasonable.  
 
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 retainer crowns and pontics. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Plan allowances for 
bridgework is limited even where the treatment plan can reasonably include a longer span bridge. As there are 
five projected pontic replacement teeth for the requested bridge, this would fall outside of the scope of the Plan 
provisions.  Our reviewer also found that given the supplied records the requested bridge does not meet Plan 
criteria for fixed bridgework. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crowns and pontics have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 4, 5, 10, and 12 and pontics 
(D6245) for tooth #'s 6, 7, 8, 9, and 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance for the Part B drugs you received on June 1, 2020.You asked the Plan to waivethe coinsurance. The Plandenied your request. The Plan says you are responsible for the cost share.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 20% coinsurance for Medicare Part B prescription drugs. Review of the file shows that you received Part B drugs on June 1, 2020. You have been asked to pay a 20% coinsurance for these services. The services 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 waivethe coinsurance for the Part B drugs you received on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided June 18, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for wound care. 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 there is no referring provider on file. 
 
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 wound care provided June 18, 2020 by an out of 
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on June 2, 2020 through 
June 4, 2020. 
 
You asked the Plan to pay for self-administered drugs. You say that the hospital would not allow you to bring 
your own medication in. The Plan denied your request. The Plan says your medical benefit does not cover self-
administered drugs. 
 
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 pay for self-administered drugs provided 
on June 2, 2020 through June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the established patient office or other 
outpatient visit (99214) provided on July 20, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay for the 
doctor's error. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $10 
copayment for physician/practitioner services.  
 
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the 
physician/practitioner 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 established patient office or other outpatient visit (99214) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDap vaccine you received. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not 
covered under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDap vaccine you received.  
 
Benefits for the vaccine 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0300, G0156, G0157, G0299) 
provided on February 1, 2020 to March 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the member was referred to you. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 
 
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 home health services (G0300, G0156, G0157, 
G0299) provided on February 1, 2020 to March 27, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonace imaging (MRI) scan of 
lower spinal canal provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for MRI of lower spinal canal. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the copayment 
applied correctly in this case. 
 
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.  
 
You have been asked to pay a $125 copayment for MRI of lower spinal canal. The service falls within the 
outpatient diagnostic tests 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 magnetic 
resonace imaging (MRI) scan of lower spinal canal provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cyanocobalamin, quantitative analysis of serum vitamin B12 
levels (83607) provided August 27, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says this service was not billed with a diagnosis that 
supports the medical necessity of the service performed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
In this case, the claim was billed with diagnosis D64.9 (Anemia, unspecified and I10 (essential primary 
hypertension), which are not listed on the LCA A56416 as diagnosis codes that support the medical necessity 
for CPT code 82607. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for cyanocobalamin, 
quantitative analysis of serum vitamin B12 levels (83607) provided August 27, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. Medicare coverage criteria are not met.  
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on March 24, 2020.You asked the Plan to waive the coinsurance for medical supplies. You say that you have never had to pay this muchbefore. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed amount is $468. The total amount you are being asked to pay is $93.60 ($468 x 20% = $93.60). Medical supplies falls within the durable medical equipment/in-network 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 medical supplies provided by a participating provider on March 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided by on May 26, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the claim should be processed for 
payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 nursing facility care provided by on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided by an out ofnetwork (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe computed tomographic angiography (CTA) of the abdomen you had on July 8, 2020.You asked the Plan to waive the deductible forthe CTA. You say that you have had this screening test every six months with no cost sharing before.The Plan denied your request. The Plan says you had not yet met your deductible when you had these services.  In addition, the plan claims that this CTA is not considered a screening test for your abdominal aortic aneurysm.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 $750 deductible that applies to diagnostic imaging services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies to diagnostic imaging services such as CTAs.  In addition, CTAs are not considered screening tests for abdominal aortic aneurysms-only ultrasounds can be considered a screening test for this purpose, and that is only allowed one time.  That is why the deductible applied here. This cost sharing is a contractual obligation that had not been met at the time the CTA was received on July 8, 2020. Therefore, we decided that the Plan does not have to waive the deductible forthe computed tomographic angiography (CTA) of the abdomen you had on July 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided. 
 
You asked the Plan to pay for the home health services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health services was not filed until January 11, 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 the home health services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrectly place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital 
inpatients or outpatients, the inpatient or outpatient hospital POS code is reported regardless of where the face-
to-face service takes place.  
 
We looked at the file and Medicare rules. The enrollee was under inpatient status when the service in question 
were provided. This means that the services must be billed with the inpatient place of service code. 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 pay for the services provided on December 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the services (A0888) provided to you on October 23, 2019. 
 
You asked the Plan to pay for the services. You say that you have never had to pay additional money. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee 
Schedule indicates that the services in question are non-covered.  
 
We looked at the file and Medicare rules. Code A0888 is assigned a status indicator of ?N" under the Physician 
Fee Schedule, which means that this code is non-covered. 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 pay 
for the services (A0888) provided to you on October 23, 2019.