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

 
We decided that the Plan does not have to the esophagogastroduodenoscopy, flexible, transoral; diagnostic, 
including collection of specimens (43235) provided on November 9, 2021. 
 
You asked the Plan to the outpatient service. You say that you have this procedure done twice per year. You 
say that you have never gotten billed for this before. You also say that you are on a limited income and cannot 
afford this bill. The Plan denied your request. The Plan says this service was performed as an outpatient 
procedure. The Plan also says that the claim processed 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 $350 
copayment per day for Outpatient hospital services.  
 
You have been asked to pay a $350 copayment per day for the outpatient service. The outpatient service falls 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 the 
esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimens (43235) 
provided on November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a magnetic resonance imaging (MRI) of the 
spine provided on December 28, 2021. 
 
You asked the Plan to waive the deductible for the MRI. You say that the procedure should be fully covered. 
The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
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 $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1,000 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the MRI was received on December 28, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for a magnetic resonance 
imaging (MRI) of the spine provided on December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are not able to pay the 
copayment. The Plan denied your request. The Plan says you have been charged the correct copayment 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 each Medicare-covered surgery at an outpatient facility.  
 
You have been asked to pay a $250 copayment for outpatient surgery. The outpatient surgery falls 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 copayment for outpatient surgery provided 
on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on January 13, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for radiology services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF 
care have not been met."] 
 
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 radiology services provided on January 13, 2022 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-cancerous growth removal procedure provided on 
February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-cancerous growth removal procedure. You say that the service was 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
skin procedure. We found no exception that would require the Plan to pay for the skin procedure. The records 
provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the non-cancerous growth removal procedure provided on February 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy with 
biopsy provided on July 2, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that it was a simple 
test, and nothing was done to charge you $350. You also say that this was the first bill you received since that 
date of service. 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 $350 
copayment for outpatient surgery in an outpatient hospital facility.  
 
 An esophagogastroduodenoscopy with biopsy is considered a surgical procedure. You have been asked to pay a 
$350 copayment for an esophagogastroduodenoscopy. An esophagogastroduodenoscopy falls 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 copayment for an 
esophagogastroduodenoscopy with biopsy provided on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 23, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 laboratory services provided on November 23, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
house/extended care facility call (D9410) provided on February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you saw your regular dentist in September 
2021. You also say that it is required by the facility you live in that you see the in-house dentist at least once in 
a 6-month timeframe. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered 
every 3 plan years. The Plan says that the frequency limit has been exceeded. The Plan also says that 
house/extended care facility call is not a covered service. 
 
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 and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on September 17, 2021. Additionally, the house/extended care 
facility call is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and house/extended care facility call (D9410) provided on 
February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for shoulder surgery provided by a network 
facility on January 17, 2022. 
 
You asked the Plan to waive the copayment for the shoulder surgery. You say that you did not have a surgical 
copayment when you had a different insurance plan. The Plan denied your request. The Plan says you have 
been asked to pay 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 $250 
copayment per visit for Medicare-covered outpatient surgery.  
 
 You have been asked to pay a $250 copayment for the shoulder surgery. The shoulder surgery falls 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 copayment for shoulder surgery provided 
by a network facility on January 17, 2022. 
  
Your complaint about the benefit structure is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthroplasty surgery provided on January 
17, 2022. 
 
You asked the Plan to waive the copayment for arthroplasty surgery. You say that when you had coverage with 
another Plan you did not have to pay copayments for services. The Plan denied your request. The Plan says you 
have been charged the correct copayment 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 $40 
copayment per visit for specialist may apply for Medicare-covered in-network physician services.  
 
 
 
 
 You have been asked to pay a $40 copayment for arthroplasty surgery. The arthroplasty surgery falls 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 copayment for arthroplasty surgery 
provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for skin graft surgery. You say that you were never informed that 
you would incur charges for this failed procedure. The Plan says that the cost-sharing amount you are being 
charged is correct. 
 
We decided that the Plan has to reduce the cost-sharing for skin graft surgery.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost-sharing information. The rules say that payment for code Q4133 is packaged into payment for other 
services. Your contract with the Plan says that enrollees must pay $100 copayment for each covered surgery 
service in an outpatient hospital. The Plan bundled payment for this claim into the payment for code Q4133, 
resulting in an allowed amount of $1,212.14 and a coinsurance amount of $242.43. However, code Q4133 is 
itself a packaged code which is not separately payable and should be packaged into the payment for the 
primary procedure code 15271, which is an outpatient surgery service that would result in an outpatient 
hospital surgery copayment of $100. Therefore, it is not appropriate for the Plan to bundle payment onto the 
line item for Q4133 and thus not appropriate to apply cost-sharing to this line item. 
 
The Plan says that you must pay $242.43 coinsurance amount for outpatient surgery. Based on your contract 
with the Plan; however, you cannot be asked to pay more than $100 copayment for outpatient surgery. 
Therefore, we decided that the Plan has to reduce the cost-sharing for skin graft surgery from $242.43 to $100.  
 
We also decided that the Plan does not have to waive the cost-sharing for skin graft surgery. 
 
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 for each covered surgery in an outpatient hospital. Therefore, we decided that the Plan does not 
have to waive the cost-sharing for skin graft surgery. 
 
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 pre-approve Udenyca, Palonosetron, Paclitaxel, Ipilimumab, 
Nivolumab and Carboplatin for the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that this drug regimen is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that they found no Medicare compendia, NCCN 
compendium or guideline, nor literature support for this regimen in this setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these drugs. Our reviewer says that 
these drugs are not medically reasonable and necessary. The requested use of Udenyca, Palonosetron, 
Paclitaxel, Ipilimumab, Nivolumab and Carboplatin is not FDA-approved for the enrollees diagnosis. The use 
of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Udenyca, Palonosetron, Paclitaxel, Ipilimumab, Nivolumab and Carboplatin for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 5, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this targeted genomic sequence 
analysis panel is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on October 5, 2021, have been met. In this case, no medical records have been provided from the enrollees 
provider indicating why this testing service had been ordered and how it would help the enrollees treatment.  
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on October 5, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750), prefabricated post and core in addition to 
crown (D2954), and endodontic therapy (D3320) provided on January 24, 2022. 
 
You asked the Plan to pay for the crown, prefabricated post and core, and endodontic therapy. You say that you 
were not aware that these services were not covered under your plan. You also say that the dentist did not 
inform you that these services would not be covered. The Plan denied your request. The Plan says these 
services are not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2750), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3320) provided 
on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for a home ventilator have not been met. 
 
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 a home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has severe COPD with chronic hypercapnic respiratory 
failure. She may benefit from bilevel positive airway pressure during sleep, with or without average volume-
assured pressure support mode. This has not been tried as an outpatient. Medicare does not cover a ventilator 
when used as bilevel positive airway pressure device. The denial is upheld.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage for facet joint injections have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are subject to the criteria listed 
in the Medicare rules section. 
 
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 facet joint injection services. Our reviewer says that the requested facet joint injection services are not medically reasonable and necessary. Our 
physician reviewer found the patient has not had formal physical therapy and has clear radicular symptoms. 
Therefore, the enrollee does not meet the criteria listed in the LCD and the request is not medically reasonable 
or 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 facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.