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

We decided that the Plan does not have to pay for the additional frames and lens sphere provided on May 17,
2021.
You asked the Plan to pay for the frames and lens sphere. You say that you were reimbursed for two pairs
when you went out-of-network in 2018. You say that you are appealing the reimbursement amount. The Plan
denied your request. The Plan says your maximum benefit has been met.
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 only covers one pair of eyeglass frames and lenses every two years.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
additional coverage of the frames and lens sphere have not been met. Specifically, the Plan paid for one pair of
frames and lenses provided on May 17, 2021, which exhausted your benefit. Therefore, we decided that the
Plan does not have to pay for the additional frames and lens sphere provided on May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT) provided May 28, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you had a stress test and you thought you did not have a copay for this. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $75 copay per visit for Medicare covered diagnostic radiology services such as MRI, CT and PET scans (not including x-rays).
You have been asked to pay $75 copay for the diagnostic services. The diagnostic service 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 myocardial perfusion imaging, tomographic (SPECT) provided May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says this will be denied as not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have respiratory failure with hypoxia and hypercapnea, but does not have a listed diagnosis of neuromuscular disease, thoracic restrictive disease, or chronic obstructive pulmonary disease. In this case, the record indicates that the enrollee has been prescribed ventilator prescription with Intelligent Volume Assured Pressure Support (IVAPS) settings. The case file does not contain a statement detailing why a bilevel positive airway pressure
(BiPAP) machine with average volume-assured pressure support (AVAPS) settings is not appropriate for this enrollee. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient surgery services provided on 
June 2 and June 9, 2021. 
 
You asked the Plan to waive the copayments for outpatient surgery services. You say that you should not be 
charged these copayments. The Plan denied your request. The Plan says the correct copayments were 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 $250 
copayment for each visit for Medicare-covered outpatient surgery.  
 
You have been asked to pay a $250 copayment for each date of service for outpatient surgery services. 
Outpatient surgery services 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 outpatient surgery services provided on June 2 and June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the nuclear stress test, myocardial perfusion imaging (MPI), echocardiography, and injections rendered on February 11, 2021.
You asked the Plan to waive the cost sharing for these services. You say that you were told by the provider that the services were covered. The Plan denied your request. The Plan says the cost sharing 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 there is a $198 yearly deductible for your covered medical services, a 20% coinsurance for Medicare-covered radiological diagnostic services, not including x-rays, and a 20% coinsurance for each Medicare-covered Part B drug.
Review of the file shows that you received radiological diagnostic services in the form of a nuclear stress test, myocardial perfusion imaging, and echocardiography on February 11, 2021. The Plan contract states that there is a $198 deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received. The Plan applied a total of $22.23 towards your yearly deductible for these services. At this time, your yearly deductible had been met.
Given that the deductible did not cover the entire cost of the services, you have also been asked to pay a 20% coinsurance for the remaining amount for these services. These services fall within the Medicare-covered radiological diagnostic services, not including x-rays, benefit category. This means that you have been asked to pay the correct amount for these services based on your contract with the Plan.
The file shows that you also received Medicare Part B drug injection services on February 11, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drug benefit category. This means that you have been asked to pay the correct amount for these services based on your contract with the Plan. The total amount you are being asked to pay for these services is $333.48. The Plan has not denied coverage for these services. 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 sharing for the nuclear stress test, myocardial perfusion imaging (MPI), echocardiography, and injections rendered on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services rendered on April 10, 2021 to 
April 29, 2021. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were told the services would be covered 
at 100 percent. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance 
for dialysis services in all places of service.  
 
Review of the file shows that you received dialysis services on April 10, 2021 to April 29, 2021. You have been asked to 
pay a 20% coinsurance for these services. These services fall within the dialysis services in all places of 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 coinsurance for the dialysis services rendered on April 10, 2021 to April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered not medically necessary and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and
investigational. Studies completed say that this procedure does not improve outcomes compared to standard
treatment of pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or
pulsed radiofrequency, is considered investigational and therefore, 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest rendered on June 21, 2021.
You asked the Plan to waive the copayment for these services. You say that the copayment is too high. 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 $275 copayment for each in-network Medicare-covered diagnostic imaging service.
Review of the file shows that you received a CT scan of the chest on June 21, 2021. You have been asked to pay a $275 copayment for these services. These services fall within the in-network Medicare-covered diagnostic imaging 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 computed tomography (CT) scan of the chest rendered on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and related services received 
on June 28, 2021. 
 
You asked the Plan to waive the deductible for the office visit and related services. You say that you feel the 
Plan should pay for these services. The Plan denied your request. The Plan says the services 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. Your 
contract with the Plan says that there is a $750 deductible that you have to pay out-of-pocket before the Plan 
will pay their share for your covered medical services. Until you have paid the deductible amount, you must 
pay the full cost of your covered services. Once you have paid your deductible, we will begin to pay our share 
of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) 
for the rest of the calendar year.  
 
The item or service you asked the Plan to waive the deductible for falls within the deductible benefit category. 

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you 
have paid the deductible amount, you must pay the full cost of your covered services. Once you have paid your 
deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share 
(your copayment or coinsurance amount) for the rest of the calendar year. This cost sharing is a contractual 
obligation that had not been met at the time the office visit and related services was received on June 28, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit and related 
services received on June 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services. 
 
You asked the Plan to pre-approve out of network physician services. You say that you prefer to see the 
requested provider. The Plan denied your request. The Plan says this treatment can be provided in 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 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 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 out of network physician 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
You asked the Plan to pre-approve a leadless pacemaker. You say that a leadless pacemaker would be appropriate for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are only covered if the enrollee is participating in a clinical research study. The medical records do not indicate the enrollee is registered for this type of study. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this drug is helpful for treatment of iron deficiency 
anemia. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no indication 
for the use of erythropoiesis stimulating agents such as Retacrit for the treatment of iron deficiency anemia. 
The review has determined that the documentation does not support that the Retacrit is medically reasonable, 
safe, effective, and necessary for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transfusion services rendered on March 15, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $250 copayment per visit for Medicare-covered surgical, IV therapy, and blood transfusion services.
Review of the file shows that you received blood transfusion services on March 15, 2021. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered surgical, IV therapy, and blood transfusion 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 the transfusion services rendered on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) thorax (71260) July 21, 2020.
You asked the Plan to waive the copayment for the diagnostic service. You say that you had COVID-19 for 6 weeks and it took you 3 months to recover your energy. You did not come to the emergency room for fatigue. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $225 copay for each Medicare covered advanced imaging service. You have been asked to pay $225 copay for the diagnostic service. Since the allowed amount is less than the
copayment amount, you are responsible for the lesser amount. The diagnostic service 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 computed tomography (CT) thorax (71260) July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 9, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan 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 out of network physician services provided to the 
enrollee on June 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional physical therapy (PT) visits.
You asked the Plan to pre-approve 24 additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 24 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been given ample time to be a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 24 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 19, 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 19, 2021.