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

 
We decided that the Plan does not have to waive the copayment for a Magnetic Resonance Imaging (MRI) on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for a Magnetic Resonance Imaging (MRI). You say that it was part 
of my prostate screening process. The Plan denied your request. The Plan says the copayment you are being 
charged 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 $225 
copayment for a Magnetic Resonance Imaging (MRI).  
 
You have been asked to pay $225 copayment for Magnetic Resonance Imaging (MRI). A Magnetic Resonance 
Imaging (MRI) 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 a Magnetic Resonance Imaging (MRI) on 
November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that the services should be covered. The 
Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $25 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $16.05 copayment for an ECG, which is less than the standard $25. ECGs 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 electrocardiogram (ECG) provided on November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was a diagnosis of non-
small cell lung cancer with PDL-1 100 percent expression. The record indicates that the enrollee has received 
24 months of treatment with the requested drug. The Food and Drug Administration (FDA) has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Keytruda is 
not reasonable and medically necessary and safe and effective 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service September 12, 2020, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive 
airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device.  You feel that you should only be required to pay what would be owed for the E0471 code since these are the 
only features of the device that you use. The Plan denied your request. The Plan says says you have been 
assessed the correct cost sharing for this device based on 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 durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related 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 rental charges for the Trilogy 100 home ventilator for date of service September 12, 2020, billed 
with code E0466.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implant services (D6010, D6053, D6055, and 
D6056), a bone graft (D6104), and guided tissue regeneration (D4266) to be provided by a participating 
provider. 
 
You asked the Plan to pre-approve endosteal implant services, a bone graft, and guided tissue regeneration. 
You say that you would like these services approved and paid. The Plan denied your request. The Plan says the 
requested dental work are not dental covered benefits. 
 
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 pre-approve 
endosteal implant services (D6010, D6053, D6055, and D6056), a bone graft (D6104), and guided tissue 
regeneration (D4266) to be provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of a pregnant uterus (76815) provided on 
November 6, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on this date. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 76816 and 76815. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76815 
is a column II code to column I code 76816. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the ultrasound of a pregnant uterus (76815) provided on 
November 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgery on May 11, 2021. 
 
You asked the Plan to waive the coinsurance for surgery. You say that you were unaware of the co-payment 
and you do not have money for this. The Plan denied your request. The Plan says the coinsurance you are being 
charged 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 a 20% 
coinsurance for surgery.  
 
You have been asked to pay a 20% coinsurance for surgery. The allowed amount of this surgery is $1987.17, 
resulting in a coinsurance amount of $397.43. 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 coinsurance for surgery on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Oxygen concentrator and portable unit 
rental on December 3, 2021. 
 
You asked the Plan to waive the coinsurance for an Oxygen concentrator and portable unit rental. You say that 
you have owned this machine since 2015 and that you do not believe you should be charged a rental on a 
machine you own. The Plan denied your request. The Plan says the 20% coinsurance you are being charged 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 20% 
coinsurance for Oxygen concentrator and portable unit rental. The allowed amount of the Oxygen concentrator 
and portable unit rental is $88.89, resulting in a coinsurance amount of $17.78. 
 You have been asked to pay a 20% coinsurance for Oxygen concentrator and portable unit rental. An Oxygen 
concentrator and portable unit rental falls within the Durable medical equipment (DME) and related 
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 coinsurance for an Oxygen concentrator 
and portable unit rental on December 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization surgery provided on November 21, 
2017, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the revascularization surgery. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 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 revascularization surgery provided on November 21, 2017, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (81479) provided on February 18, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that the treating physician in this case is part of the 
Plan's network of participating providers. You also say that this type of personalized patient case management 
is not available through any of the laboratories currently in the Plan's network. The Plan denied your request. 
The Plan says the non-urgent services are not authorized because the provider is a non-network provider with 
the Plan, and another non-network provider with the Plan referred the member for 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 pathology services (81479) provided on February 
18, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for Urology and Prescription 
services on February 23, 2021 to September 1, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for Urology and prescription services. You say 
that you are requesting reconsideration of your responsibility of the paid claims. The Plan denied your request. 
The Plan says the copayment you are being charged 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 a $30 
copayment for each Urology service visit and 20% coinsurance for prescription services. The total allowed 
amount of the prescriptions is $4,862, resulting in a coinsurance amount of $972.40. There were 3 Urology 
service visits, resulting in a copayment amount of $90. Therefore, your total cost-sharing amount is $1,062.40. You have been asked to pay a $30 copayment, 20% coinsurance for Urology and prescription services. Urology 
and prescription services falls within the Medicare Part B prescription drugs 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 and coinsurance for Urology and Prescription services on February 23, 
2021 to September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies rendered by the out-of-network (OON) 
provider on October 22, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the medical supplies rendered by the out-of-network (OON) provider on October 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic panel testing provided on October 14, 
2021. 
 
You asked the Plan to pay for panel testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this panel testing should 
have been reported with one unit of unlisted test code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results and there is no procedure code that describes the procedure, the lab must report a 
miscellaneous/unlisted procedure code with a single unit of service.  
 
We looked at the file and Medicare rules. This lab testing was not billed with the appropriate coding. Based on 
this information, we decided that Medicare rules for coverage of panel testing have not been met.  
  
Therefore, we decided that the Plan does not have to pay for pharmacogenomic panel testing provided on 
October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81194, 81206, 81210, 81235, 81275, 
81276, 81292, 81295, 81298, 81301, 81309, 81317, 81401) provided on June 17, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81194, 81206, 81210, 81235, 81275, 81276, 81292, 
81295, 81298, 81301, 81309, 81317, 81401) provided on June 17, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI), any joint of upper extremity 
(73221). 
 
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says that medical necessity has not been 
established as no appropriate clinical records was submitted to support the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records indicate that the enrollee has suffered a cutaneous neuropraxis of the posterior 
branch of the left radial nerve. There is no motor deficit or weakness. According to the note there is no 
indication of surgery and the numbness may resolve over the course of 6-12 months however investigation of 
the radial nerve at the elbow makes sense to determine if there is a surrounding hematoma etc. Plain x-rays 
were normal. Of note the enrollee has cervical spine degenerative changes and the opinion of the provider is 
that the left forearm symptoms are not related to cervical radiculopathy. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI), any joint of upper extremity (73221).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 1, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says for the 
member to receive the hearing benefits, the member must go to an in-network appointment that has been set by 
the Plans hearing vendor so that they can give the clinic access to the members hearing benefits and properly 
send the referral before the member orders hearing aids.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you see the Plans hearing vendors provider.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a provider 
with the Plans hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aids provided on November 1, 2021.