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

We decided that the Plan does not have to waive the deductible for laboratory services provided on August 6, 
2020. 
 
You asked the Plan to waive the deductible for laboratory services. You say that the normal lab you use was 
too busy so you had to go to another lab and feel that this is the reason you are being charged a deductible. 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. Your 
contract with the Plan says that there is a $250 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received laboratory services provided on August 6, 2020. The record shows that you had paid $0 toward 
the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed 
amount of $54.19.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services 
was received on August 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory services provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain fused to base metal crown (D2751) for tooth #30. 
 
You asked the Plan to pre-approve the dental service. You say that you have a broken tooth. You also say that 
your broken tooth is causing you to feel very uncomfortable. The Plan denied your request. The Plan says that 
that there are 12 points of teeth in biting contact. The Plan also says that the crowns are not medically 
necessary. 
 
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. The Plan covers the dental 
service 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 dental service. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the provided documentation indicates 
that tooth #30 appears to have a large restoration and a distal fracture. The reviewer found that a crown 
restoration is reasonable to return tooth #30 to good masticatory function. Therefore, the reviewer found that 
the crown for tooth #30 is medically reasonable and necessary. 
 
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 dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a porcelain fused to base metal crown (D2751) for tooth #30.  
 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on August 24, 
2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for the copay. The Plan denied your request. The Plan says the copay is correct. 
 
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 outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for physical therapy. This service falls within the outpatient 
rehabilitation 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 physical 
therapy provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth service provided on June 26, 2020. 
 
You asked the Plan to pay for the prolonged evaluation and management service before and/or after direct 
patient care; first hour. You say that the Plan should pay this claim. The Plan denied your request. The Plan 
says the code submitted is not a telephone evaluation and management service code according to their PHP 
Payment Policy 92.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99358 is Prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99358 is not the correct code for telephone services based on the CMS Covered 
Telehealth Services for the COVID-19 Pandemic. Based on this information, we decided that Medicare rules 
for coverage of prolonged evaluation and management service before and/or after direct patient care; first hour 
(99358) have not been met. Therefore, we decided that the Plan does not have to pay for the telehealth service 
provided on June 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging (including subtraction, when 
performed); with tomographic (SPECT) (CPT Code 78071). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says the calcium level is within the normal range and the criteria for Sestamibi parathyroid 
scan is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the services. Our physician reviewer 
found imaging studies should be performed only after the diagnosis of primary HPT is established on the basis 
of biochemical findings. National Institutes of Health (NIH) guidelines recommend parathyroidectomy in all 
symptomatic patients and asymptomatic patients younger than 50 years although some authors recommend 
more expansive criteria for surgical therapy.  Preoperative localization studies are increasingly becoming the 
standard of care, as they enable minimally invasive surgical techniques. Many surgeons advocate for 2 
concurrent examinations to definitively identify the site of disease, and almost all authors advocate for 
intraoperative parathyroid hormone level monitoring. Preoperative localization studies are also critical in 
patients with prior neck surgery or recurrent postoperative hypercalcemia. These patients can be particularly 
challenging for the imager because of distortion of normal anatomic landmarks and an increasing incidence of 
ectopic adenomas. Parathyroid scanning has no role in establishing the diagnosis of this condition. Its primary 
 
 
utility lies in detection of specific loci of hyperfunctioning tissue with an aim toward therapy. In this case, the 
calcium level is within the normal range and the criteria for Sestamibi parathyroid scan is not met. The review 
has determined that the requested parathyroid planar imaging (including subtraction, when performed); with 
tomographic (SPECT) (CPT Code 78071) is not medically necessary or reasonable. 
 
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 parathyroid planar imaging (including subtraction, when performed); with tomographic 
(SPECT) (CPT Code 78071).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on November 6, 
2019. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the tests couldn't be performed at 
urgent care, so you were brought to the ER. You say that you should only pay the urgent care copayment. The 
Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Medicare-covered emergency room visits. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you received services in the ER. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the ER visit provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 17, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 subsequent nursing facility care provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve progressive lenses. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that progressive lenses are non-covered. 
 
We looked at the file and Medicare rules. The services at issue are progressive lenses. These services are 
denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve 
progressive lenses.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray you received on January 9, 2020. 
 
You asked the Plan to waive the copayment . You say that you should not have to pay $100 for this. The Plan 
denied your request. The Plan says you are responsible for the copayment. 
 
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 an x-ray provided by a specialist at an outpatient hospital.  
 
Review of the file shows that you had an x-ray at an outpatient hospital on January 9, 2020. You have been 
asked to pay a $100 copayment for the x-ray. The x-ray 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 the x-ray you received on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist services and ultrasounds 
provided from March 3, 2020, to June 2, 2020. 
 
You asked the Plan to waive the copayments for specialist services and ultrasounds. You say that you disagree 
with the charges because you only saw the nurse and the ultrasound was done for a few seconds only. 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. Your contract with the Plan also clearly says that you must pay a $90 
copayment for radiological diagnostic services. 
 
You received specialist services on March 3, 2020. Therefore, you are responsible to pay the $35 copayment.  
 
You received an ultrasound on March 3, 2020. Therefore, you are responsible to pay the allowed amount of 
$38.89, which is less than the $90 copayment.   
 
You received an ultrasound on June 2, 2020. Therefore, you are responsible to pay the allowed amount of 
$39.02, which is less than the $90 copayment.   
 
 
 
The total amount you owe is: $112.91. 
 
You have been asked to pay the total amount of $112.91 for specialist services and ultrasounds. Specialist 
services fall within the physician/practitioner services, including doctor's office visits benefit category. 
Ultrasounds 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 copayments for specialist services and ultrasounds provided from March 3, 
2020, to June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry procedure provided on April 20, 2020. 
 
You asked the Plan to pay for the podiatry services. You say that the Plan is legally required to pay for these 
services. The Plan denied your request. The Plan says these IHS services have not been correctly billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment to IHS providers for outpatient services 
is made based on an AIR. All outpatient hospital services should be reported under revenue code 0510. 
 
The services at issue were provided by an IHS provider on an outpatient basis. These costs were not reported 
under revenue code 0510 as required. Therefore, we decided that the Plan does not have to pay for the podiatry 
procedure provided on April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator rental provided from 
February 20, 2019, to June 20, 2019, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the portable oxygen concentrator rental. You say that the enrollee was not 
informed that this provider was OON. The Plan denied your request. The Plan says the services were billed 
correctly per the enrollee's plan benefits. 
 
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 portable oxygen concentrator rental provided 
from February 20, 2019, to June 20, 2019, 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 lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat lumbar epidural steroid injection. You say that you need the repeat 
injection for pain relief. The Plan denied your request. The Plan says you only had 10% relief of pain from the 
previous epidural steroid injection and therefore does not meet Medicare guidelines. 
 
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 a repeat lumbar epidural steroid 
injection. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee did not achieve significant pain relief from 
the prior injection and therefore, 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 a repeat lumbar epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, alignable 
system (CPT Code L5910), all lower extremity prostheses, flex-walk system or equal (L5981), addition to 
lower limb prosthesis, vertical shock reducing pylon feature (L5988), and all endoskeletal lower extremity 
prosthesis, axial rotation unit, with or without adjustability (L5984). 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the request for K3 prosthesis exceeds your needs and does not 
meet Medicare criteria as reasonable and necessary. The Plan states the requested socket accessories are not 
reasonable and necessary for the approved preparatory prosthesis. 
 
 
 
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 services have not been met. The advanced foot and other items 
are still denied per Medicare rules. The records show that the request is for a preparatory prosthesis. The notes 
do not show why the requested foot and other items are needed. That is why the requested items are still 
denied. A request for a foot that meets your needs and Medicare guidelines can be reviewed if submitted. 
Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, 
alignable system (CPT Code L5910), all lower extremity prostheses, flex-walk system or equal (L5981), 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988), and all endoskeletal lower 
extremity prosthesis, axial rotation unit, with or without adjustability (L5984).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a 
participating provider on July 28, 2020. 
 
You asked the Plan to waive the copayment for diagnostic radiology services. You say that five years ago there 
were no co-pays when you had these tests done. 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 $75 
copayment for outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $75 copayment for diagnostic radiology services. Diagnostic radiology services 
fall within the outpatient diagnostic tests/diagnostic radiology 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 diagnostic radiology services provided by a participating provider on 
July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you depend on the hospital staff to verify 
eligibility. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the rendering facility is also out-of-network. 
 
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 
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 physician services provided on May 25, 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 from June 14, 2019 to June 
19, 2019. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not think you should have to pay 
for these drugs because the provider could not tell you what they were for. The Plan denied your request. The 
Plan says the denial of payment for these drugs is correct, because these drugs are not covered by Medicare 
Part B and you should request reimbursement under your Medicare Part D prescription benefits. 
 
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 
from June 14, 2019 to June 19, 2019.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.