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

 
We decided that the Plan does not have to waive the deductible for lab services you received on May 21, 2020. 
 
You asked the Plan to waive the deductible for the lab services. You say that you have never had to pay for 
routine lab tests before and you will not pay this. The Plan denied your request. The Plan says you had not yet 
met your deductible at the time of these lab services, so you were charged this amount appropriately. 
 
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 $198 deductible for Medicare Part B services.  
 
The lab services you received are considered Medicare Part B services. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $198 deductible for Medicare Part B services. This cost 
sharing is a contractual obligation that had not been met at the time the lab services were received on May 21, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for lab services you received 
on May 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on July 2, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this ultrasound was for 
maintenance per your doctor's orders. 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 $160 
copayment for outpatient diagnostic tests/radiological diagnostic service.  
 
You have been asked to pay $110.48 which is less than your copayment amount of $160 for an ultrasound. The 
correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient 
diagnostic tests/radiological diagnostic service benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided by a participating provider on July 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the intravenous (IV) hydration provided during an outpatient hospital 
visit on July 17, 2020, billed with code 96360. 
 
You asked the Plan to pay for the IV hydration. You say that this was provided as treatment for elevated 
sodium levels. The Plan denied your request. The Plan says that payment for the above is included in the 
payment for the chemotherapy administration or nonchemotherapy injection and infusion service. 
 
The Plan must follow Medicare rules. Medicare rules say that hydration codes are used to report IV infusion of 
normal saline or electrolyte solutions. Fluid used to administer drugs is not separately payable as it is 
considered incidental hydration. 
 
In this case, there is no indication that this IV saline was administered as part of an IV infusion of any drug. 
The records show that this saline hydration was provided as a direct treatment for the patient's elevated sodium 
levels. The billed code is correct and appropriate to report IV hydration when not used in the administration of 
any other drugs/substances. Therefore, we decided that the Plan has to pay for the intravenous (IV) hydration 
provided during an outpatient hospital visit on July 17, 2020, billed with code 96360.  
 
 
 
 
 
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on June 20, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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, we have confirmed that code 71045 
for the x-ray services has a bundled relationship with code 32555 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on 
June 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiologic examination, ankle (73610) 
radiologic examination, foot (73630) provided July 13, 2020. 
 
You asked the Plan to waive the copayment for the x-rays. You say that according to your plan your copay for 
x-rays is $50 and this is the amount you paid upon your visit. However you just received a bill for an additional 
$15.46. The Plan denied your request. The Plan says the claim processed and the correct copayment was 
applied per the plan benefits. 
 
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 $50 
copayment for each Medicare-covered standard x-ray service. 
 
You have been asked to pay $65.46 copayment for the x-rays. You had 2 x-rays. The allowed amount for 
73610 was $33.76. The allowed amount for 73630 was $31.70. The allowed amount for both x-rays were lower 
than the $50 copayment. The x-rays fall 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 the radiologic examination, 
ankle (73610) radiologic examination, foot (73630) provided July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device and sleeves provided on 
July 6, 2020. 
 
You asked the Plan to pay for a pneumatic compression device and sleeves (E0675, E0673). You say that the 
enrollee's physician ordered the DME to prevent the enrollee from developing Deep Vein Thrombosis. The 
Plan denied your request. The Plan says a pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device and sleeves provided on July 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not meet Medicare criteria for SNF admission. 
 
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 that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses provided on July 15, 2020. 
 
You asked the Plan to pay for the progressive lenses. You say that bifocals did not work, as you kept tripping 
and stumbling. You say that with progressive lenses you have had none of the problems. You say that your eye 
problems come from rheumatoid arthritis and the medications used to control it. You say that it will be a 
hardship to wear bifocals at this time in your life. You say that you have always received coverage for 
progressive lenses in the past. The Plan denied your request. The Plan says progressive lenses are not a covered 
benefit under your contract. 
 
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 covers standard lenses and standard frames up to a maximum of $75 every 2 years. 
 
 
 
We looked at the file and the Plan's rules. The records show that the lenses in dispute were progressive and not 
standard. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses provided on 
July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2020, by an OON 
provider. 
 
You asked the Plan to pay for nursing facility care. You say that these medically necessary services were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 July 2, 2020, by 
an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic colonography (CTC) services. 
 
You asked the Plan to pre-approve the CTC services. The Plan denied your request. The Plan says the 
requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colorectal 
cancer screenings are nationally non-covered. Therefore, we decided that the Plan does not have to pre-approve 
computed tomographic colonography (CTC) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for conebeam computed tomography (CT) capture and 
interpretation with field of view of both jaws, with or without cranium, (D0367), joint survey, single view, 2 or 
more joints (specify) (77077), diagnostic casts (D0470), and 2D oral/facial photographic image obtained intra-
orally or extra-orally (D0350) provided on January 27, 2020. 
 
You asked the Plan to pay for conebeam CT capture and interpretation with field of view of both jaws, with or 
without cranium, Joint survey, single view, 2 or more joints (specify), Diagnostic casts, and 2D oral/facial 
photographic image obtained intra-orally or extra-orally. You say that the services rendered should be covered. 
The Plan denied your request. The Plan says the provider is not a certified provider to have received the 
services and no authorization is on file, and there is no dental coverage for services received, therefore, the 
claims denied correctly since Medicare cannot make payment for items and services furnished. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of conebeam CT capture and interpretation with field of view of both jaws, with or without cranium, 
Joint survey, single view, 2 or more joints (specify), Diagnostic casts, and 2D oral/facial photographic image 
obtained intra-orally or extra-orally have not been met. Specifically, the record indicates that the provider at 
issue was not enrolled with Medicare for the date of service at issue. There was no documentation to verify the 
provider's enrollment in Medicare for the date of service at issue.  Therefore, we decided that the Plan does not 
have to pay for conebeam computed tomography (CT) capture and interpretation with field of view of both 
jaws, with or without cranium, (D0367), joint survey, single view, 2 or more joints (specify) (77077), 
diagnostic casts (D0470), and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) 
provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99214) provided on November 6, 
2019. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there were network providers available who could provide the services 
at issue. 
 
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 service 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 physician services (99214) provided on November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis 
provided on July 21, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that your dental 
plan allows 2 cleanings and checkups each year. The Plan denied your request. The Plan says your benefits 
were applied correctly based on your plan coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental 
benefit maximum. The contract says that you are responsible for amounts beyond the benefit limit. The record 
shows that you met the annual maximum benefit on January 29, 2020, and your annual maximum benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, 
bitewings, and prophylaxis provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payments for specialist visits provided. 
 
You asked the Plan to waive the co payments for specialist visits. You say that you feel that you should only 
owe a $25 co payment for specialist visits. 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 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
co payment for specialist visits. 
 
You received specialist visits. Therefore, you are responsible to pay a $35 
co payment per each visit. The total amount you owe is: $70.   
 
You have been asked to pay the total co payment amount of $70 for specialist visits. Specialist visits fall 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 co payments for specialist visits provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 20, 2020 to May 4, 
2020 by a non-network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 April 20, 2020 to May 4, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services rendered on April 
13, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial 
hardship. The Plan denied your request. The Plan says the copayment was 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 $65 
copayment for each covered urgently needed service.  
 
Review of the file shows that you received urgent care services on April 13, 2020. You have been asked to pay 
a $65 copayment for these services. These services fall within the covered urgently needed service benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the urgent care services rendered on April 13, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the enrollee has severe dry eye syndrome. The Plan 
denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 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 pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 2, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network ophtalmologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are contractually required to obtain this service from network providers. 
 
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 referral to an out-of-network ophtalmologist.