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

 
We decided that the Plan does not have to waive the copayments for X-rays of the shoulder and a duplex scan 
(ultrasound) of extremity veins provided from March 22, 2022, to March 23, 2022. 
 
You asked the Plan to waive the copayments for the X-rays and ultrasound. You say that you were referred for 
the services and were not made aware of any copayments. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $15 
copayment for each standard X-ray service and a $185 copayment for radiological diagnostic services, such as 
ultrasounds.  
 
You have been asked to pay a $15 copayment for the X-rays. You have also been asked to pay $94.06 for the 
ultrasound, which is less than the $185 copayment per the EOC. The total for both services is $109.06. The X-
rays and ultrasound 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 X-rays of the shoulder and a duplex scan 
(ultrasound) of extremity veins provided from March 22, 2022, to March 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you received the bill after you 
met your out-of-pocket maximum for the year. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $30 
copayment for each physical therapy visit.  
 
The file shows that the out-of-pocket maximum had not been met at the time the claim was received and 
processed by the Plan. Therefore, you have been asked to pay a $30 copayment for the PT services. The PT services fall 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 (PT) services provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased on May 20, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you were told these glasses were authorized. The 
Plan denied your request. The Plan says you had already exhausted your eyewear benefit for the year when you 
purchased eyeglasses on February 28, 2022.  Another pair of glasses is not covered. 
 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 eyewear only once per calendar year. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for 
eyeglasses you purchased on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA Next Generation Sequencing (NGS) test 
provided on April 19, 2022. 
 
You asked the Plan to pay for the Prism RA testing. You say that this test is only performed by your lab and 
was ordered by the patient's doctor to inform the patient's treatment. The Plan denied your request. The Plan 
says this test is not covered. The Plan must follow Medicare rules. Medicare rules say that in order for any 
NGS testing to be covered, the test must have FDA approval or clearance. The PrismRA test does not currently 
have FDA approval or clearance. Based on this information, we decided that Medicare rules for coverage of the 
Prism RA testing have not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA 
Next Generation Sequencing (NGS) test provided on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tdap vaccination you received on April 6, 2022. 
 
You asked the Plan to pay for the Tdap vaccination. You say that you went to your doctor's office for a routine 
check-up, but the receptionist told you that you would be getting a wellness exam.  You said that the doctor 
told you that you would need the Tdap vaccination to complete your wellness exam. The Plan denied your 
request. The Plan says this vaccination is not covered under your medical benefits for preventive reasons. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap 
vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly 
exposed to any illness related to the Tdap vaccination. Therefore, we decided that the Plan does not have to pay 
for the Tdap vaccination you received on April 6, 2022.  
 
Benefits for the Tdap vaccination 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81161, 81479, 81286, 81413, 81414, and 
81442 billed for date of service December 9, 2021. 
 
You asked the Plan to pay for procedure codes 81161, 81479, 81286, 81413, 81414, and 81442. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
payment for code 81161 is bundled into payment for code 81413. The Plan says the remaining codes are not 
covered for screening purposes. 
 
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 81161 
is a column II code to column I code 81413. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  
 
Medicare rules also say that screening tests, with the exception of the few tests listed in the Medicare rules 
section, are not covered. The remaining codes at issue in this appeal (81479, 81286, 81413, 81414, and 81442) 
were requested solely for screening purposes. Medicare does not cover these tests solely for screening 
purposes.  
 
Therefore, we decided that the Plan does not have to pay for procedure codes 81161, 81479, 81286, 81413, 
81414, and 81442 billed for date of service December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta. 
 
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 self-administered drugs are not covered. 
 
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 Vyzulta.  
 
Benefits for these services 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 waive the copayments for radiation therapy treatment provided from 
January 13, 2022, to March 23, 2022. 
 
You asked the Plan to waive the copayments for the radiation treatment. You say that each treatment session 
should only cost a total of $30. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 $30 
copayment for each radiation therapy service. 
 Date of Service Copayment per EOC Actual Charges 
January 13, 2022 $30 $14.85 
February 10, 2022 $30 $14.85 
March 10, 2022 $30 $14.85 
March 23, 2022 $30 $30.00 
Total: $120 $74.55 
 
You have been asked to pay a total of $74.55 for the radiation treatment, which is less than the copayment total 
per the EOC. The radiation treatment 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 copayments for radiation therapy 
treatment provided from January 13, 2022, to March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 2, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the test should be fully covered. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 
copayment for X-rays, laboratory and other diagnostic tests.  
 
You have been asked to pay a $10 copayment for the lab services. The lab services 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 laboratory services provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for back injections performed from June 3, 
2021, to December 9, 2021. 
 
You asked the Plan to waive the copayments for the injections. You say that you cannot afford the copayments. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $475 
copayment for each outpatient hospital facility visit.  
 
You have been asked to pay a $475 copayment for each of the three injections, for a total of $1,425. The 
injections fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 back 
injections performed from June 3, 2021, to December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care (PCP) office visit provided 
on April 23, 2022. 
 
You asked the Plan to waive the copayment for the PCP visit. You say that the visit was COVID-19 related and 
should not have a copayment. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 $10 
copayment for each visit or consultation with your PCP.  
 
You have been asked to pay a $10 copayment for the PCP visit. The PCP 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 primary care (PCP) office visit provided on April 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for eye procedures provided from March 17, 2022, to 
March 31, 2022. 
 
You asked the Plan to waive the cost for eye procedures. You say that these procedures have cost you too much 
money, and you were told they would be covered. The Plan denied your request. The Plan says the cost applied 
was 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 $395 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. Additionally, two of your procedures were not covered by the plan, ($1540 + $1145 = $2,685). 
 
You have been asked to pay a $2,685 cost for eye procedures. Eye procedures fall within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cost for eye procedures provided from March 
17, 2022, to March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient testing (87491, 87070, 87086, 87591) provided 
on May 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
  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 had network providers 
available who could have provided 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 outpatient testing (87491, 87070, 87086, 
87591) provided on May 18, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on May 2, 2022. 
 
You asked the Plan to waive the copayment for a chest x-ray. You say that you were told there wouldn't be a 
copayment for this service. The Plan denied your request. The Plan says the copayment applied was 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 $110 
copayment for Radiological Services.  
 
You have been asked to pay the allowed amount of $80.92, which is less than the $110 for a chest x-ray. A 
chest x-ray falls within the Radiological 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 a chest x-ray provided on May 2, 2022.
Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve home health aide services. We decided that the Plan does not have 
to pre-approve home health skilled services.  
 You asked the Plan to pre-approve home health skilled services and home health aide services. You say that the 
services are necessary. The Plan says that based on the documentation provided, coverage criteria have not 
been met. 
 
We decided that the Plan has to pre-approve home health aide services.  
 
The Plan follows Medicare rules. Medicare rules say that home health services are covered when specific 
criteria are 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 pre-approve home health aide services. Our 
reviewer says that the services are medically necessary. Our physician reviewer found aide services are 
reasonable based on the need to support functional improvement with physical and occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have been met. Therefore, we decided that the Plan 
has to pre-approve home health aide services.  
 
We also decided that the Plan does not have to pre-approve home health skilled services. 
 
The Plan follows Medicare rules. Medicare rules say that home health services are covered when specific 
criteria are 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 pre-approve home health skilled services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found that criteria are met 
for skilled therapy services but are not met for skilled nursing services as the enrollee's chronic medical 
conditions are stable and do not require skilled nursing observation or intervention. The nursing focus on pain 
is duplicative of the occupational therapy plan of care and not medically 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 home health skilled services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health skilled services. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits for treatments provided 
from January 11, 2022, to March 8, 2022. 
 
You asked the Plan to waive the copayments for specialist visits for treatments. You say that you are 
questioning why the payments for these treatments are so high. You did not need to pay all these extra 
copayments last year. The Plan denied your request. The Plan says the copayments applied were 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 $30 
copayment for physician/practitioner services, including doctors office visits ($30 copayment X 4 days = 
$120.00 + partial copayment $14.85 = $134.85).  
 
You have been asked to pay a $134.85 copayment for specialist visits for treatments. specialist visits for 
treatments falls within the Physician/Practitioner Services, Including Doctors 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 copayments for specialist visits for treatments 
provided from January 11, 2022, to March 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from SNF care. The Plan 
denied your request. The Plan says the records do not show that the enrollee has completed their full course of 
care in the current facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. The enrollee appears to be at/near a plateau in function. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs are custodial and intermittent and can, as a practical matter, be provided at 
a lower level of care. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on October 28, 2021. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
October 28, 2021.