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

 
We decided that the Plan has to hold you harmless for laboratory services provided on November 19, 2019. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because you did not know these tests would not be covered. The Plan denied your request. The 
Plan says that these services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services provided on November 19, 2019.  
 
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 waive the copayment for the CT scan provided on July 20, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were informed it would cost 
$180 for the CT scan. You say that you shouldn't have to pay the additional cost. 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 $275 
copayment for advanced imaging services at an in-network outpatient hospital.  
 
You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the CT scan provided on July 20, 2020.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for a lipid panel. We decided that the Plan does not have to pay for a 
thyroid and thyroxine tests and a glucose test.  
 
You asked the Plan to pay for a lipid panel. You say that these services were medically necessary. The Plan 
says that rules for payment have not been met. 
 
We decided that the Plan has to pay for a lipid panel.  
 
The Plan follows Medicare rules. The rules say that Medicare covers cardiovascular disease screening tests for 
the purpose of early detection of cardiovascular disease in individuals without apparent signs or symptoms of 
cardiovascular disease who have not had the screening tests paid for by Medicare during the preceding 59 
months following the month in which the last cardiovascular screening tests were performed. 
 
In this case, the record does not show that the enrollee has apparent cardiovascular disease signs/symptoms. 
The record does not document that the enrollee has had the screening test paid for by Medicare during the 
preceding 59 months following the month in which the last cardiovascular screening tests were performed. 
Therefore, we decided that the Plan has to pay for a lipid panel (80061) received on July 31, 2020.  
 
We also decided that the Plan does not have to pay for a thyroid and thyroxine tests and a glucose test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, a thyroid and thyroxine tests and a glucose test, were requested solely for 
screening purposes. Medicare does not cover thyroid and thyroxine tests solely for screening purposes. The 
available medical records do not support that the enrollee has risk factors as described above to be eligible for a 
diabetes screening. The enrollee is not eligible for a glucose test. Therefore, we decided that the Plan does not 
have to pay for a thyroid (84443) and thyroxine (84439) tests and a glucose test (82947) received on July 31, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Caris MI profile testing provided on March 30, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary and should be 
covered. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because 
this testing is not FDA-approved and has not had a Medicare technology assessment performed. 
 
The Plan follows Medicare rules. Medicare rules state that next-generation sequencing tests are only covered 
when certain specific requirements have been met.  
 
 
 
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 pay for genetic testing. Our reviewer says that this 
testing does not meet the Medicare criteria for coverage. Our physician reviewer found this testing is not FDA-
approved and does not otherwise meet Medicare criteria for use in the enrollee's type of cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for Caris MI profile testing provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the physicians services. 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 physician's services provided on 
April 23, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided to you on May 27, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that these services 
are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. You received the services with the reasonable expectation that the services were be 
covered under your plan. Therefore, we decided that the Plan has to pay for the lab services provided to you on 
May 27, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure provided on August 5, 2020. 
 
You asked the Plan to pay for the vasectomy. You say that no one told you the procedure would not be 
covered. The Plan denied your request. The Plan says the services are excluded from your benefits as per the 
Evidence of Coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vasectomy have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical procedure provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral radiographic image (D0230) provided 
on July 7, 2020. 
 
You asked the Plan to pay for the additional intraoral radiographic image. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says you have exhausted 
your benefit for the 2020 calendar year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file, and Medicare rules. The case file indicates that the Plan has already provided coverage 
for one intraoral X-ray in 2020. Therefore, you have exhausted the coverage for additional intraoral 
radiographic images. Based on this information, we decided that the Plan's rules for coverage of the additional 
intraoral radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for 
the additional intraoral radiographic image (D0230) provided on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on July 10, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery for the supplies provided in this case. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the lumbar-sacral orthosis provided on July 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
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 
physician services provided to the enrollee on May 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tibial fracture treatment (27530) provided on March 4, 2020. 
 
You asked the Plan to pay for tibial fracture treatment. You say that this was billed correctly. The Plan denied 
your request. The Plan says this should have been billed once bilateral. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 27530 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of tibial fracture treatment have not been met. 
Therefore, we decided that the Plan does not have to pay for tibial fracture treatment (27530) provided on 
March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for recement of crown (D2920) performed on June 29, 2020. 
 
You asked the Plan to pay for recement of crown. You say that you cannot afford this service. The Plan denied 
your request. The Plan says rules for payment have not 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. 
 
We looked at the case file and Medicare rules. The Plan covers recement of crown with 100% enrollee 
responsibility once per tooth per 12 months. Based on this information, we decided that the Plan's rules for 
coverage of recement of crown have not been met. Therefore, we decided that the Plan does not have to pay for 
recement of crown (D2920) performed on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zoll Life Vest rom November 6, 2020 through 
November 28, 2020. 
 
You asked the Plan to pre-approve the Zoll Life Vest. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says the member did not have an 
ejection fraction of less than or equal to 35%. 
 
 
 
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 Zoll Life Vest. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Zoll life vest was not indicated for treatment after November 5, 2020 once the left 
ventricular ejection fraction had improved above 35% in the absence of documented ventricular arrhythmia. 
 
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 Zoll Life Vest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Zoll Life Vest rom November 6, 2020 through November 28, 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 neurosurgeon.
You asked the Plan to pre-approve these services. You say that you do not want to delay surgery. The Plan
denied your request. The Plan says the services are available 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 neurosurgeon.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on February 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services are 
not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on February 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental x-rays (D0210) you received on August 13, 2020. 
 
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says this is only covered once 
every 3 years. 
 
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 services are subject to a 
benefit limitation. The Plan covers intraoral x-rays once every 3 years. The records show that you were 
provided covered intraoral x-rays on February 25, 2019. This means that the requested x-rays exceed the 
benefit limit and are not covered. Therefore, we decided that the Plan does not have to pay for the dental x-rays 
(D0210) you received on August 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide 12 visits for home health physical therapy, 12 visits licensed 
practical nurse and 9 visits for skilled nursing. 
 
You asked the Plan to provide 12 visits for home health physical therapy, 12 visits licensed practical nurse and 
9 visits for skilled nursing. You say that the services are medically necessary. The Plan denied your request. 
The Plan says the member is not homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 provide 12 visits for home health physical therapy, 
12 visits licensed practical nurse and 9 visits for skilled nursing. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the patient is not homebound and does not meet the 
definition of home health aide services per Section 50.2 and the request for home health aide services are not 
reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy, licensed practical nurse, and skilled nursing have not been 
met. Therefore, we decided that the Plan does not have to provide 12 visits for home health physical therapy, 
12 visits licensed practical nurse and 9 visits for skilled nursing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy X-Ray absorptiometry (DEXA) scan provided 
on February 6, 2020. 
 
You asked the Plan to pay for DEXA scan. You say that you are appealing. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the documentation submitted is not 
sufficient to determine how the enrollee came to this provider or whether the service was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due and the amount of payment.  
 
We looked at the file and Medicare rules. No medical records were provided to the Plan. The Plan requested 
supporting records, but they were not provided. Without this information, you have not furnished sufficient 
information to justify payment of the claim as it has been billed. Based on this information, we decided that 
Medicare rules for coverage of DEXA scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a dual-energy X-Ray absorptiometry (DEXA) scan provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses received on September 2, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you received a notice of denial. The Plan denied 
your request. The Plan says the claims have been processed correctly per your 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 anything 
over $500 for supplemental eyewear.  
 
Review of the file shows that the eyeglasses total cost was $509. The plan paid their responsibility of $500. 
You have been asked to pay the remaining $9 for the eyeglasses. The eyeglasses fall within the vision 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 pay for the eyeglasses received on September 2, 2020.