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

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on March 25, 2021. 
 
You asked the Plan to waive the copayment for x-ray. You say that you should not have a copayment for the x-
ray because they should be included in the lump sum of your surgeries. The Plan denied your request. The Plan 
says copayment 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 $30 
copayment for each Medicare-covered standard x-ray service.  
 
  You have been asked to pay $30 copayment for the x-ray. The x-ray falls within the Outpatient Diagnostic 
Test 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. The x-ray is not considered a fully covered service under 
the global surgery package. 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 x-ray provided 
on March 25, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the portion of the rendered genetic testing provided on October 25, 
2021, billed with code 81479. 
 
You asked the Plan to pay for the portion of the testing coded as 81479. You say that this testing was deemed 
medically necessary by the treating provider. The Plan denied your request. The Plan says that this testing was 
initiated by the lab and not the treating physician, meaning that plan-directed care cannot apply. This is 
noncovered for cardiovascular screening. 
 
Please note: We reviewed the Plans rationale and find it is not compelling. There is ample evidence that the 
in-network treating physician ordered this testing including a signed attestation to that effect. In addition, due 
to the enrollees medical conditions related to cardiovascular disease, this cannot be considered a screening test 
and is not limited by what cardiovascular screenings are covered.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the portion of the testing coded as 81479 by a contract provider. The file does not 
show that the plan provided notice that the portion of the testing coded as 81479 would not be covered. The 
Plan also agreed to pay for most of the codes reported on this claim. No specific rationale to deny only code 
81479 was provided. Under Medicare rules, this means the portion of the testing coded as 81479 is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the portion of the rendered genetic 
testing provided on October 25, 2021, billed with code 81479.  
 
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 pay for an Office Visit provided on November 1, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an Office Visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 an Office Visit provided on November 1, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on January 
11, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that these claims were covered in the 
past. 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 $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the office visit was received on January 11, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for a specialist office visit 
provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on December 7, 
2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the endodontic therapy. You say that you feel it is unfair for you to be charged 
for services provided by doctors that are not Medicare providers. The Plan denied your request. The Plan says 
this service was rendered by a provider who has opted out of Medicare. The plan was also informed by a 
representative of the provider's that prior to the services being rendered, you were advised that they did not 
participate in or accept your dental insurance, and that you signed a financial contract stating that you would be 
responsible for the charges. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy (D3330) provided on December 7, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two resin-based composites (D2331 x2) provided 
on September 23, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you would like these services to be 
processed for payment. The Plan denied your request. The Plan says you received the problem focused limited 
oral evaluation before your plan's coverage began. Your dental coverage was effective as of February 1, 2021. 
The Plan also says that your claim for the resin-based composites processed correctly. 
 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, you are responsible for a 50% 
coinsurance for each resin-based composite that is received in-network. Therefore, we decided that the Plan 
does not have to pay for the two resin-based composites (D2331 x2) provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), anterior resin-based composite (D2332), and posterior resin-based composite (D2393) provided from 
November 9, 2021, to December 13, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis, and resin-based composites. 
You say that you were never told that you had to go to a dentist that accepts Medicare. The Plan denied your 
request. The Plan says you received these services from a provider who chose not to receive Medicare funds. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), anterior resin-
based composite (D2332), and posterior resin-based composite (D2393) provided from November 9, 2021, to 
December 13, 2021 by a Medicare opt out provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve multigene panel testing provided to the enrollee on July 29, 2021. 
 
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your 
request. The Plan says that the off-label use of molecularly-targeted agents outside of clinical trials is not 
encouraged. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found per the National Comprehensive Cancer Network (NCCN) guidelines for bladder cancer molecular 
profiling may be considered stage IIIB disease. This will help guide therapy decision-making. The service is 
reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have been met. Therefore, we decided that the Plan has to pre-
approve multigene panel testing provided to the enrollee on July 29, 2021.  
 
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 Mavenclad Pak. 
 
You asked the Plan to pre-approve the Mavenclad Pak. You say that the enrollee has a diagnosis of Multiple 
Sclerosis (MS) since 1995. You say that Mavenclad will give the enrollee the benefit she needs to slow her MS 
progression, but without the risk of long-term suppression. The Plan denied your request. The Plan says the 
medication being requested does not fall under Part B coverage. The Plan says that the enrollee does not have 
pharmacy benefits administered under this contract. The Plan says that the enrollee has prescription coverage 
provided through Express Scripts. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mavenclad Pak.  
 
Benefits for the Mavenclad Pak may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on April 12, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was insufficient support provided in the documentation how this genetic testing would reasonably lead to a significant change in treatment and overall improvement on outcome compared to standard 
treatment for this patient's conditions. Therefore, this request for cardiac risk assessment genetic screening 
testing will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on April 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for air ambulance services provided on 
October 20, 2021. 
 
You asked the Plan to waive the coinsurance for air ambulance services. You say that the helicopter ride would 
have been totally unnecessary if your local hospital would have admitted you. You also say you cannot afford 
any more medical payments. 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 20% 
coinsurance for out-of-network air ambulance services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$1,075.42, which is 20% coinsurance of the allowed amount for air ambulance services ($5,377.09 allowed 
amount x 20% coinsurance = $1,075.42). You have also been asked to pay $230.68, which is 20% coinsurance 
for air ambulance mileage ($1,153.40 allowed amount x 20% coinsurance = $230.68). You have been asked to pay a total of $1,306.10 ($1,075.42 coinsurance + $230.68 coinsurance = $1,306.10). Air ambulance services 
falls within the Ambulance 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 coinsurance for 
air ambulance services provided on October 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
January 24, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you believe you 
should have only been charged $175. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay when, 
in-network, a $315 copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility.  
 
 
  You have been asked to pay $315 for outpatient surgery services. Outpatient surgery 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 outpatient 
surgery services provided on January 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 21, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the provider did not perform the 
correct tests that were recommended by your PCP. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 emergency room (ER) visit 
provided on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services provided on 
January 28, 2022. 
 
You asked the Plan to waive the copayment for Emergency Room Services. You say that you would like to 
request reconsideration of the denied claim. 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 a $120 
copayment for Emergency Room Services.  
 
You have been asked to pay a $120 copayment for Emergency Room Services. Emergency Room Services falls 
within the Emergency Care 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 Emergency 
Room Services provided on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on September 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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, the CPT Code Manual definition of code 00840 is "Anesthesia for intraperitoneal procedures in 
lower abdomen including laparoscopy; not otherwise specified." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation support an "open 
right inguinal hernia repair with mesh/ incarcerated incisional hernia repair." In this case, the service was 
reported with an inappropriate anesthesia code, and the more appropriate anesthesia code to report is CPT 
00830.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on September 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a pelvic ultrasound provided on December 
10, 2021. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that the Plan did not pay any of the 
bill. 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 $110 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a total of $45.08, which is less than the $110 copayment for the ultrasound. The 
ultrasound 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 reduce the copayment for a pelvic ultrasound provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) provided on 
November 17, 2021. 
 
You asked the Plan to pay for the maxillary interim partial denture. You say that you were told this procedure 
was covered before any work was done. You also say that you were not told any details of what was covered or 
not covered in relation to the denture. The Plan denied your request. The Plan says this service is not covered 
under the Plan. 
 
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 
maxillary interim partial denture (D5820) provided on November 17, 2021.