Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for vision frames (V2020), and single lenses (V2100). We decided that 
the Plan does not have to pay for the fundus photography (92250) and an additional $20 towards the medical 
eye examination (92004).  
 
You asked the Plan to pay for vision frames (V2020), single plano lenses (V2100), a medical eye examination 
(92004), and fundus photography (92250) provided from December 10, 2021, to December 28, 2021. You say 
you were told by the provider that your charges were covered by your insurance. The Plan says that the out-of-
network copayment for routine eye exam covers up to $40. The Plan also says that fundus photography is not 
covered for routine supplemental benefits. The Plan also says that single vision lenses and frames are not 
covered. 
 
We decided that the Plan has to pay for vision frames (V2020), and single lenses (V2100).  
 
The Plan contract also says that there is a $300 (combined in and out-of-network) benefit toward the purchase 
and fitting of eyeglasses and pair of lenses.  
 
The record shows that the vision frames (V2020) and single lenses (V2100) are a total of $244.95, which is less 
than the $300 benefit. Therefore, we decided that the Plan has to pay for vision frames (V2020), and single 
lenses (V2100).  
 
We also decided that the Plan does not have to pay for the fundus photography (92250) and an 
additional $20 towards the medical eye examination (92004). 
 
The Plan contract vision care benefit excludes fundus photography (92250). The Plan contract says that they 
cover $40 towards a routine eye exam.  
 
The record shows that fundus photography is excluded from the Plan vision care benefit. The record also shows 
that your medical eye examination was $60, which is $20 more than the $40 allowance ($60 - $40 = $20). 
Therefore, we decided that the Plan does not have to pay for the fundus photography (92250) and an additional 
$20 towards the medical eye examination (92004). 
 
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19083 billed for services provided on 
January 26, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on March 17, 2022. Comparison of the claims shows that the claim lines are exact duplicates. There 
is no evidence presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 19083 billed for services provided 
on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular RFA. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this procedure is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of RFA of the genicular nerves is still being evaluated and is considered 
experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology visit provided on July 18, 
2022. 
 
You asked the Plan to waive the copayment for a cardiology visit. You say that your treatment at this facility 
was not satisfactory. You will not be going there again. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $50 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay a $50 copayment for a cardiology visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 cardiology visit provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show at least 50% improvement from the previous procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that you have had greater than 50% pain relief for six months. The request is 
deemed not medically reasonable and 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 pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid. 
 
You asked the Plan to pre-approve Nuplazid. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
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 Nuplazid.  
 
 
 Benefits for Nuplazid 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on April 12, 2022. 
 
You asked the Plan to waive the coinsurance for part B drugs. You say that you cannot afford the coinsurance 
amount of $282.60 every six weeks. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs. The allowed amounts of 
these drugs total $1414.02, resulting in a total coinsurance amount of $282.80. 
 
You have been asked to pay 20% coinsurance for part B drugs. This item/service falls within the Medicare-
covered Part B chemotherapy drugs and other Part B 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 coinsurance for Medicare Part B prescription drugs provided on April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on July 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you are appealing services rendered on July 27, 2022, 
stating the services were ordered as STAT and there was no time to obtain an authorization. The Plan denied 
your request. The Plan says an authorization was not obtained prior to diagnostic imaging 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 an x-ray provided on July 27, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a shoulder immobilizer provided on  
May 20, 2022. 
 
You asked the Plan to waive the deductible for a shoulder immobilizer. You say that you should not be 
responsible to pay for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $125 deductible which applies to durable medical equipment.  
 
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $125 
deductible which applies to durable medical equipment. This cost sharing is a contractual obligation that had 
not been met at the time a shoulder immobilizer was received on May 20, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a shoulder immobilizer provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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, for 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 April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 08, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you would like to appeal the 
claim for the copayment for date of service July 8, 2022.  You say that it was a follow-up appointment after 
having surgery and should not have a copayment. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $40 
copayment for physician/practitioner service. 
 
You have been asked to pay a $40 copayment for a specialist visit. This item/service falls within the 
physician/practitioner service 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 specialist 
visit provided on July 08, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper tablet 10mg for the enrollee. 
 
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no pharmacy benefit with the enrollee's plan. 
 
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 Prochlorper tablet 10mg for 
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Camzyos. 
 
You asked the Plan to pre-approve Camzyos. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Camzyos.  
 
Benefits for Camzyos 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on June 
24, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you felt this should be 
covered because paying this copayment would be financial strain. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $250 
copayment for per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $250 copayment for outpatient diagnostic test. This item/service falls within the 
per day for other Medicare-covered diagnostic radiology services that are not ultrasounds 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 diagnostic test provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee is being treated for diabetes with 
chronic kidney disease and proteinuria. You say that review of current labs showed hyperkalemia and iron 
deficiency anemia, requiring iron intravenous (IV) treatments. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. 
 
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 Injectafer. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the available medical records do not 
support that the enrollee has tried oral iron supplementation and has demonstrated significant gastrointestinal 
distress whereas compliance with an oral regimen is no longer feasible, or that the enrollee has a pathological 
or anatomical presentation where oral iron is unlikely to be absorbed or may cause further exacerbation of the 
underlying gastrointestinal disorder.  The available medical records do not support that the requested drug is 
medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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, for 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 May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the enrollee has been successfully treated with 
Orencia. The Plan denied your request. The Plan says Orencia to be administered at home is not covered under 
the Part B benefit. 
 
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 Orencia.  
 
 Benefits for Orencia 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital service provided on July 
8, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that it should be billed as 
preventative. The Plan denied your request. The Plan says this cost sharing was charged 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 $325 
copayment for same-day outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay $325 copayment for outpatient hospital service. This item/service falls within the 
same-day outpatient surgery in an outpatient hospital facility 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 hospital service provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation (D7953). You say that you 
are appealing the denial. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 bone replacement graft for ridge 
preservation (D7953) is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve the bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 7, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on May 17, 2022.