Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 30, 2020.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that preventive services would supersede the $200 amount. You say that dental expenses will surpass preventive costs without adequate treatment. The Plan denied your request. The Plan says the maximum amount allowed 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, you also have an annual allowance of $200. The Plan agreed to pay $200 toward the dental services received on January 21, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that the results of this testing will alter medical 
management. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found although she has breast cancer, she is ER+ and diagnosed at age 66 with no other relatives with breast 
cancer. The requirements 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management service provided on 
January 10, 2020. 
 
You asked the Plan to pay for hospital discharge day management. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the evaluation and management service was bundled as part of the 
global surgical fee that was performed on January 9, 2020. 
 
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 Global Period for the surgery is 90 days. There is no modifier for transfer of care. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge day management have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management 
service provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve orthopedic equipment. You say that you would like approval to see this 
provider. You say that they off robotics and 3-D imaging for knee surgery. The Plan denied your request. The 
Plan says there are in-network orthopedists who can provide 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 
orthopedic equipment to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical information provide does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found if the last C1-C2 injection did not provide significant relief, it should not be repeated. The 
request is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat facet injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest you received on July 20, 2020.
You asked the Plan to waive the coinsurance for the LifeVest. You say that you tried this vest but couldn't use it. You said that you returned it a few days later, so you shouldn't have to pay for this. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. Records show that you were provided with a LifeVest. You had this item for several days before it was returned. The way that rented durable medical equipment works is that if you have the item for up to a month or any portion thereof, you are responsible for the rental charges for that month. You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment 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 LifeVest you received on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress. 
 
You asked the Plan to pre-approve a semi-electric hospital bed with mattress. You say that you need a semi-
electric hospital bed to help transfer from bed to wheelchair. The Plan denied your request. The Plan says the 
documentation submitted does not show you have a medical condition which requires elevation of the 
head/upper body or positioning of the body in ways not feasible with an ordinary bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
 
 
We looked at review the file, and Medicare rules. The medical record does not support the criteria. Based on 
this information, we decided that Medicare rules for coverage of a semi-electric hospital bed with mattress have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed 
with mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you have tremors and your current tanks are 
heavy. The Plan denied your request. The Plan says the item is a duplicate of your current equipment. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary oxygen concentrator with portable oxygen tanks. These items serve 
the same purpose as the requested portable oxygen concentrator. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) rendered by the out of network (OON) provider on June 1, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the fundus photography with interpretation and report (92250) rendered by the out of network 
(OON) provider on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant consultation to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve a cochlear implant consultation. You say that you do not feel like this 
cochlear implant can be provided in-network. 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 
a cochlear implant consultation to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain (70450). 
 
You asked the Plan to pre-approve a CT scan of the brain. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are not abnormal labs or other test results. 
 
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 brain. Our reviewer 
says that the requested CT scan is not medically necessary at this time. Our physician reviewer found the 
records show that the the enrollee has a history of headaches. The enrollee is noted to have previously 
undergone a CT scan of the head in 2019 for the same indication. That scan showed age related atrophy and no 
acute findings. The enrollee has now been seen by a new provider for their headaches. The enrollee's 
neurological exam was unremarkable. There were otherwise no other changes noted in the member's condition 
since the time of prior imaging that would suggest an intracranial process. There are no new findings that 
would generally warrant repeat testing at this time. 
 
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 brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the brain (70450).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 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 codes 81240, 81241, 81291, 81400, 81401, 81479, 82955, 81225, 81226, 
81227 and 81355 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81240, 81241, 81291, 81400, 81401, 81479, 82955, 81225, 81226, 81227 and 81355 
are not supported in the medical record. Specifically, the file contains only an order for a comprehensive 
metabolic panel; there is no documentation listing exactly what tests were ordered. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to adjust the coinsurance for the eyewear provided on June 17, 2020. 
 
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the coinsurance has been applied 
correctly to the eyewear provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
 
 
Additionally, the rules say that Medicare generally does not cover routine vision and eyewear services. 
However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, 
the Plan's coverage rules apply in this case. 
 
The Plan says you must pay $91.20 for the eyewear provided. Based on the Plan contract however, payment in 
the amount of $200 should be issued for the purchase and fitting of eyeglasses at a network optical provider. 
The Plan allowed amount for the eyeglasses provided was $222.80 in which the $200 eyewear benefit applies. 
Your coinsurance responsibility is $22.80 ($222.80 Plan allowed amount-$200 benefit). Therefore, we decided 
that the Plan has to adjust the coinsurance from $91.20 to $22.80 for the eyewear provided on June 17, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left L4-5 radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in pain. The Plan denied your 
request. The Plan says there was only one set of medial branch blocks. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the guidelines requires two sets of diagnostic medial branch blocks which produce 80% pain relief. 
Therefore, at this point, the request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left L4-5 radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your 
cardiologist on June 29, 2020. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you spoke with the doctor for 
less than ten minutes during this telehealth visit, so you don't think you should have to pay a copayment. The 
Plan denied your request. The Plan says you were charged this copayment 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 $45 
copayment for specialist visits (including telehealth services).  
 
You have been asked to pay a $45 copayment for the telehealth visit. This copayment applies regardless of how 
long the visit lasts. 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 telehealth visit you had with 
your cardiologist on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4267 x 3) and the bone 
replacement graft for ridge preservation (D7953 x 3). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says guided 
tissue regeneration is not listed as a covered service. The Plan says bone replacement graft for ridge 
preservation is not listed as a covered service either. 
 
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 
guided tissue regeneration (D4267 x 3) and the bone replacement graft for ridge preservation (D7953 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because the visit was only 5 minutes long. 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 $35 
copayment for specialist services. 
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on June 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the conization of the cervix provided on 
July 28, 2020. 
 
You asked the Plan to waive the copayment for the conization of the cervix. You say that you already pay too 
much for the plan and cannot afford the 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 $395 
copayment for outpatient surgery.  
 
You have been asked to pay a $395 copayment for the conization of the cervix. The conization of the cervix 
falls within the outpatient hospital coverage 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 conization of the cervix provided on July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services rendered on June 10, 2020. 
 
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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.  
 Therefore, we decided that the Plan does not have to pay for the outpatient surgical services rendered on June 
10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from October 14, 2019 to October 18, 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that providers must enter the appropriate numeric revenue 
code on the UB-04 form. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct revenue 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the services rendered from October 14, 2019 
to October 18, 2019.