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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 3, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this was a follow up ultrasound so 
it should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $100 
copayment per day for a Medicare-covered ultrasound. 
 
You have been asked to pay $96.70 which is less than the standard $100 copayment for an ultrasound. 
Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an ultrasound provided on February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and heel stabilizer (L3170) 
provided on March 3, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis and heel stabilizer. You say that you would like this claim 
reprocessed and approved for payment based on the submitted documentation. The Plan denied your request. 
The Plan says documentation required for payment is missing. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation does not indicate the ordering provider discussed the medical 
necessity of the ordered equipment with the enrollee. 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 ankle foot orthosis (L1971) and heel stabilizer (L3170) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $7.30 more for the routine vision hardware. We decided that the Plan does 
not have to pay in full for the routine vision hardware.  
 
You asked the Plan to pay more for the routine vision hardware. You say that you are a diabetic, will seek 
treatment when you feel the need, and believe the Plan should cover this bill. The Plan says that you have met 
your annual maximum benefit for routine vision hardware.  
We decided that the Plan has to pay $7.30 more for the routine vision hardware.  
 
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 up to $200 every two calendar years for routine vision hardware. 
 
We looked at the file and the Plan's rules. The routine vision hardware was denied by the Plan because they 
said your routine vision hardware benefit has been exhausted. However, the record shows that the Plan only 
paid $192.70 toward the routine vision hardware provided on April 19, 2022. Based on this information, we 
decided that the Plan's rules for coverage of the routine vision hardware have been met. Therefore, we decided 
that the Plan has to pay $7.30 more for the routine vision hardware.  
 
We also decided that the Plan does not have to pay in full for the routine vision hardware. 
 
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 up to $200 every two calendar years for routine vision hardware. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $192.70 toward the routine 
vision hardware provided on April 19, 2022. We have told the Plan that they must pay another $7.30 toward 
these services, which will exhaust your routine vision hardware benefit. Based on this information, we decided 
that the Plan's rules for coverage of the routine vision hardware have not been met. Therefore, we decided that 
the Plan does not have to pay in full for the routine vision hardware. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services provided from 
October 18, 2021, to March 2, 2022. 
 
You asked the Plan to waive the copayments for the chiropractic services. You say that you felt pain after a 
neck adjustment and you feel you should not be responsible for the following visits to correct it. 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 $20 
copayment for each chiropractic visit.  
 
The file shows you had a total of 15 chiropractic visits from October 18, 2021, to March 2, 2022. Therefore, 
you have been asked to pay a $20 copayment for each visit for the chiropractic services. The total for all visits 
is $300 ($20 copayment x 15 visits = $300). The chiropractic services fall within the Chiropractic 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 copayments for chiropractic services provided 
from October 18, 2021, to March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a phlebectomy procedure. 
 
You asked the Plan to pre-approve a phlebectomy. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
covered for the indications established in the applicable LCD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a phlebectomy. Our reviewer says that a 
phlebectomy is not medically reasonable and necessary in this case. Our physician reviewer found that the 
clinical documentation in this case does not support that the veins in question are greater than 4 mm in 
diameter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a phlebectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a phlebectomy procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), polycarbonate lens (V2784), and anti-
reflective coating (V2750) provided on February 22, 2022. 
 
You asked the Plan to pay for the glasses. You say that you had a stroke in July 2021, and your vision changed 
after the stroke. The Plan denied your request. The Plan says there is no coverage for the eyewear you 
purchased. The Plan also says that there were no contacts to the Health Plan prior to the purchase in regard to 
your cost share or provider questions for these services. 
 
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 these services when they are provided after cataract surgery. 
 
We looked at the file and the Plan's rules. The record does not show that these glasses were provided after 
cataract surgery, and you state your vision changed after having a stroke, which is why you needed these 
glasses. Based on this information, we decided that the Plan's rules for coverage of the glasses have not been 
met. Therefore, we decided that the Plan does not have to pay for the frames (V2020), polycarbonate lens 
(V2784), and anti-reflective coating (V2750) provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be somewhat unstable and requires additional short-term acute 
care services that can be safely administered at the current facility until more stable and appropriate for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on March 21, 2022. 
 You asked the Plan to pay for the orthoses. You say that this claim met the coverage criteria. The Plan denied 
your request. The Plan says there was no face-to-face exam. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The file shows that a prefabricated foot (L3170) was provided. The records do not show that the enrollee 
suffers from diabetic foot disease and does not wear a leg brace. An ankle-foot orthosis (L1971) was also 
provided. The records do not show that the enrollee had weakness or deformity requiring stabilization. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the orthoses provided on March 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal care services provided from December 3, 2021, 
to January 2, 2022. 
 
You asked the Plan to pay for the personal care services. You say that you would like your home care to be 
paid for. The Plan denied your request. The Plan says the service is not covered by Medicare. The Plan also 
says that the services rendered are custodial in nature and you did not require any skilled therapy services or 
medical and social services. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
personal care services provided from December 3, 2021, to January 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 3, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy. The Plan denied your request. The Plan says the test should only bill as a single 
unit on a given date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The genetic testing was billed with multiple codes. The rules say that this 
panel of tests should be billed with one code and one unit of service. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on April 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A and B vaccine received on February 28, 
2022. 
 
You asked the Plan to pay for the Hepatitis A and B vaccine. You say that you went on a business trip to 
Mongolia where the risk of Hepatitis A is high. The Plan denied your request. The Plan says the services 
received are not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A and 
B vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A and 
B vaccine. In addition, the documentation does not support that you fall within the high risk or intermediate 
risk group categories listed above. Therefore, we decided that the Plan does not have to pay for the Hepatitis A 
and B vaccine received on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on December 28, 
2021, to December 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you are appealing the denied 
service. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved 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 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 hospital services provided on 
December 28, 2021, to December 29, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on March 
4, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you would like the 
copayment waived. The Plan denied your request. The Plan says the proper copayment was applied for the 
service that was rendered. 
 
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 Network lab services and diagnostic procedures/tests.  
 
  You have been asked to pay a $30 copayment for the laboratory services. The laboratory services fall within 
the Outpatient Hospital 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 laboratory services provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) provided on March 17, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the frames. You say that the frames are not available where you live. You also 
say that you have already made the payment which exceeds the quota for eyeglasses. The Plan denied your 
request. The Plan says the treating provider is OON. The Plan also says that there is no pre-authorization 
process, and no referral from the primary physician. 
 
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 these services when an authorization is obtained for OON covered services. 
 
We looked at the file and the Plan's rules. Specifically, the frames were provided OON, and an authorization 
was not obtained. Based on this information, we decided that the Plan's rules for coverage of the frames have 
not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) provided on 
March 17, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory services provided on January 
8, 2022 to March 5, 2022 by an out-of-network (OON) provider. 
 
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 rendered by an out-of-network provider without 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 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 office visit and laboratory services provided on 
January 8, 2022 to March 5, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on January 12, 
2022. 
 
You asked the Plan to pay for the service. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no medical record to support the necessity for this screening test. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder test provided to the enrollee on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 4, 2022. 
 
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 January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are included in the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pacemaker test provided on March 2, 
2022. 
 
You asked the Plan to waive the copayment for a pacemaker test. You say that you have never paid a 
copayment for a pacemaker check before and should not have to pay one now. 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 $50 
copayment for Medicare-Covered Diagnostic Procedures/Tests.  
 
You have been asked to pay a $50 copayment for a pacemaker test. A pacemaker test falls within the Medicare-
Covered Diagnostic Procedures/Tests benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
pacemaker test provided on March 2, 2022.