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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
experimtental/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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from 
December 27, 2021, to December 29, 2021. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you expected your 
insurance to cover a greater portion of this bill. The Plan denied your request. The Plan says this claim was 
processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 20% 
coinsurance for inpatient hospital care.  
 
You have been asked to pay $2,493.85 for the inpatient hospital care. The provider billed the Plan a total of 
$23,879.42 for these services, but the allowed cost for this care is $14,307.37. This is the amount used to 
calculate your coinsurance ($14,307.37 x 20%= $2,861.47). The Plan states in their letter dated June 17, 2022, 
that you were assessed a lower copayment due to a system issue, but because this was a Plan error you will not 
be held responsible for the full 20% coinsurance, and your bill remains $2,493.85. 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 inpatient hospital stay provided from December 27, 2021, to December 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment and coinsurance for a vision care visit and eye 
injection provided on March 7, 2022. 
 
You asked the Plan to reduce the copayment and coinsurance for the vision care visit and injection. You say 
that your cost share should be the same for each visit. The Plan denied your request. The Plan says the correct 
copayment and coinsurance 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 $35 
copayment for vision services in a specialist's office. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $35 copayment for the vision care visit. The vision care visit falls within the 
Vision Care benefit category. You have also been asked to pay $27.14 for the injection, which is 20% of the 
allowed amount ($135.72 allowed amount x 20% coinsurance = $27.14). The injection falls within the 
Medicare Part B Prescription Drugs benefit category. The total for the visit is $62.14. 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 reduce the copayment and coinsurance for a vision care visit and eye injection provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 2021. Therefore, 
we decided that the Plan does not have to pre-approve a partial upper denture.
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 (71250) provided on April 7, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have not had to pay a copayment 
for this service in the past. The Plan denied your request. The Plan says this claim was processed correctly, and 
your copayment was assessed in accordance with your contract. Diagnostic radiology services other than 
ultrasounds require a $250 copayment. However, the allowed cost for the service at issue is lower than your 
required copayment, so you are being asked to pay a lesser 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 $250 
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $132.68 copayment for the CT scan. A CT scan falls within the Medicare-
covered 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 
the computed tomography (CT) scan of the chest (71250) provided on April 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation services 
(A0429, A0425) provided on October 8, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that these services were 
medically necessary, and the copayment is too costly. The Plan denied your request. The Plan says this claim 
was processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $230 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $230 copayment for ambulance transportation. 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 ambulance transportation services (A0429, A0425) provided on October 8, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 1, 2022, to 
January 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 inpatient hospital services provided on January 1, 
2022, to January 14, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided January 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that  genetic testing panels that include the FANCC 
gene are statutorily excluded service. 
 
We looked at the file and Medicare rules. This service is non-covered. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services (0037U) provided January 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99203) provided on March 29, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in 
function. The Plan contract states that supplemental coverage is provided for a chiropractic initial evaluation   
once per calendar year.  
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of this service have been met. Specifically, the Plan provides coverage of a chiropractic evaluation 
once per calendar year although Medicare does not. Therefore, we decided that the Plan has to pay for the 
office visit (99203) provided on March 29, 2022.  
 
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 Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Professional Counselor (LPC) from January 31, 2022, to February 23, 2022. 
 
You asked the Plan to pay for the LPC services. You say that you were told you could get reimbursed for these 
services. The Plan denied your request. The Plan says the provider you used is not eligible to participate in 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The services in dispute 
were rendered by a LPC, which is not an eligible provider type. Therefore, we decided that the Plan does not 
have to pay for outpatient mental health services you received from a Licensed Professional Counselor (LPC) 
from January 31, 2022, to February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network urgent care visit provided on 
April 13, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you should not have this 
copayment. 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 $15 
copayment for diagnostic procedures and tests - urgent care center.  
 
You have been asked to pay a $15 copayment for an urgent care visit. An urgent care visit falls within the 
Diagnostic Procedures and Tests - Urgent Care Center benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an in-network urgent care visit provided on April 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayments to $20 for the psychotherapy services provided on 
January 14, 2021, February 11, 2021, and March 12, 2021. We also decided that the Plan does not have to fully 
waive the copayments for the psychotherapy services.  You asked the Plan to waive the copayments for the psychotherapy services. You say that these were all phone 
visits and feel they should be covered. The Plan says that you have been charged the correct cost sharing 
amount. 
 
We decided that the Plan has to reduce the copayments for the psychotherapy services provided on 
January 14, 2021, February 11, 2021, and March 12, 2021.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). The Plan says that you must pay a $40 copayment for each therapy 
visit. Based on the Plan contract, however, you cannot be asked to pay more than a $20 copayment for each 
therapy visit. Therefore, we decided that the Plan has to reduce the copayments to $20 for the psychotherapy 
services provided on January 14, 2021, February 11, 2021, and March 12, 2021. All other copayments were 
correctly applied with the $20 copayment. 
 
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 code 83789-59 billed for date of service January 11, 2022. 
 
You asked the Plan to pay for code 83789-59. You say that You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says procedure code 83789-59 is not supported. It is included 
in codes G0481 and 80307. The medical records do not support that this service was distinct or independent 
from the other services performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 83789-59 Our reviewer says that the 
medical records do not support the use of the -59 modifier with code 83789. Our physician reviewer found the 
medical records do not support the use of procedure 83789 as the billed procedure codes of G0481 and 80307 
include the procedure code 83789. There is no support for the 83789-59 to be billed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 83789-59 billed for date of service January 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that this drug is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have 
not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Darzalex Faspro. Our reviewer says 
that this drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial 
of Bortezomib or Velcade before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects 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 Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy (97124) and the hot or cold packs 
therapy (97010) provided on March 23, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the massage therapy (97124) and the hot or cold packs therapy (97010) 
provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
February 7, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the physician provided medically 
necessary services in good faith. The Plan denied your request. The Plan says non-emergent, non-urgent 
services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64405-50 billed for date of service January 
17, 2022. 
 
You asked the Plan to pay for procedure code 64405-50. You say that you billed this service with the correct 
number of units, so this claim should be paid. The Plan denied your request. The Plan says without medical 
records the Plan cannot determine if these services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. In this case, you have not supplied any medical records to support the necessity of 
these billed services.  The Plan has sent you seven separate requests for medical records and there has been no 
response to date.  Without medical records, the appropriateness or the correct billing of these services cannot be 
verified. Therefore, we decided that the Plan does not have to pay for procedure code 64405-50 billed for date 
of service January 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 22, 2021. 
 
You asked the Plan to pay for the medical services. You say that you believe you filed this claim timely. The 
Plan denied your request. The Plan says you did not file this claim timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until March 3, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for medical services provided on January 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health visits (990837) provided on 
March 1, 2022, to March 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health visits. You say that this enrollee has been a patient 
of yours for years. The Plan denied your request. The Plan says the services have been 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 mental health visits (990837) 
provided on March 1, 2022, to March 11, 2022, by an out-of-network (OON) provider.