Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the routine vision hardware provided on January 19, 
2022.  
You asked the Plan to pay more for the routine vision hardware. You say that you have routine hardware 
benefits which should be covered by the Plan. The Plan denied your request. The Plan says the claim processed 
with the maximum allowance of $300. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 per calendar year for routine vision hardware. 
 
We looked at the file and the Plan's rules. The record shows that your $300 allowance was exhausted on 
January 19, 2022. Based on this information, we decided that the Plan's rules for coverage of the routine vision 
hardware have not been met. Therefore, we decided that the Plan does not have to pay more for the routine 
vision hardware provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided on June 19, 2020. 
 
You asked the Plan to pay for code 99239. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for code 99239 was not filed until August 27, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge day management services (99239) provided on June 19, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test purchased on January 16, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that you received 3 different letters from 
the Plan, two denials and then 1 letter that says that reimbursements prior to February 15, 2022 will be covered. 
You also say that the information is confusing and feel you should be reimbursed. The Plan denied your 
request. The Plan says this was not a covered benefit at the time of purchase. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the at-home 
COVID-19 test purchased on January 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be more stable and improving and should only require short-
term additional acute care hospital services that can be completed at the current facility until more appropriate 
for a lower level of care. The patient does not require services at the LTACH that are not already available at 
the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be somewhat unstable and requires short-term additional acute 
care hospital services that can be completed at the current facility until the patient is more stable and 
appropriate for transfer. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as the patient is clinically unstable and as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954) and a crown 
(D2750), provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated post and core and a crown. You say that you feel like these 
services should be covered. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post 
and core (D2954) and a crown (D2750), provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
October 20, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the providers rely on facility staff 
to verify eligibility and obtain authorization from the patients insurance company. The Plan denied your 
request. The Plan says the services were not urgent or emergent in nature and an authorization was not obtained 
prior to the services being rendered and the provider is not participating with the member's Plan. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue 
regeneration (D4266). 
 
You asked the Plan to pre-approve graft and tissue regeneration. You say that these dental services are 
medically necessary. The Plan denied your request. The Plan says a bone replacement graft (D4263) and 
guided tissue regeneration (D4266) are not covered by your dental 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 a 
bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on September 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 a home health visit provided on September 27, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 20, 
2020. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered since 
you were admitted into the hospital. 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 $200 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  
 
 
 
 You have been asked to pay $200 copayment for ambulance transport. Ambulance transport 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 copayment for ambulance transport 
provided on March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the contrast used in the MRI provided on 
November 29, 2021. 
 
You asked the Plan to waive the coinsurance for the contrast used in the MRI. You say that the contrast should 
be included in the total cost and not be charged a separate fee for it. The Plan denied your request. The Plan 
says the coinsurance 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 20% 
coinsurance for each Medicare covered Part B drug.  
 
 
 
 You have been asked to pay a total of $131.69 which consists of the $105 copayment for the MRI and the 20% 
coinsurance for the contrast used in the MRI. You have been asked to pay $26.69 which is 20% of the allowed 
amount for the contrast. The allowed amount is $133.47(20% x $133.47= $26.69). The contrast used in the 
MRI 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 coinsurance for the contrast used in the MRI provided on November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for stress test provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for stress test. You say that you were told it would only be a $90 
copayment not $250. 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 $250 
copayment for Medicare-covered sleep studies and stress tests. 
 
You have been asked to pay $250 copayment for the stress test. Stress tests 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 stress test provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a comprehensive eye exam provided on 
February 24, 2022. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that your copayment should only be 
$45 for a specialist. 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 $50 
copayment per visit for vision care services.  
 
You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the Vision 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 reduce the copayment for a comprehensive eye exam 
provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), a core build-up (D2950), and an 
unspecified preventative procedure (D1999), provided by a participating provider on October 22, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for a crown, a core build-up, and an unspecified preventative procedure. You say 
that you believe the Plan should pay for this. The Plan denied your request. The Plan says the rendered dental 
work 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 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for a crown (D2740), a core build-up (D2950), and an unspecified preventative procedure (D1999), 
provided by a participating provider on October 22, 2021, to December 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve integrated fold-down push handles and side guards for a 
manual wheelchair. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested side guards are for use outside of the home. Although this item may be helpful, neither Medicare 
nor the Plan covers equipment for use outside the home. The fold-down push handles are not needed to propel 
the approved wheelchair. Therefore, we decided that the Plan does not have to pre-approve integrated fold-
down push handles and side guards for a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of lymph nodes (38525) provided on December 
22, 2021. 
 
  You asked the Plan to pay for the biopsy of lymph nodes (38525). You say that the surgical assistant was 
chosen by the surgeon and the assistant could not deny the services to the patient. You say that all services 
were medically necessary and payment in full to the assistant should be made. The Plan denied your request. 
The Plan says procedure code 19303 and 38900 have been approved. The Plan also says procedure code 38525 
remains denied as an assistant surgeon may not be paid for this service. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 38525. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
biopsy of lymph nodes (38525) have not been met. Therefore, we decided that the Plan does not have to pay for 
the biopsy of lymph nodes (38525) provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings identified with code 
A6549. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 
 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although these items may be appropriate for you, they do not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient 
compression stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81275, 81276 and 81301) 
provided on June 7, 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 claim has not been billed in 
accordance with Medicare billing 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. 
 We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81275, 81276 and 81301) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit provided by an out-
of-network (OON) provider on January 25, 2022. 
 
You asked the Plan to waive the coinsurance for the OON office visit. You say that the claim was denied in 
error. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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% 
coinsurance for each out-of-network (OON) specialist visit.  
 
You have been asked to pay $39.50, which is 30% of the allowed amount for the OON office visit ($131.68 
allowed amount x 30% coinsurance = $39.50). The OON office visit falls within the Physician/Practitioner 
Services, Including Doctor's 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 coinsurance 
for a specialist office visit provided by an out-of-network (OON) provider on January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the MRIs provided on February 9, 2022. 
 
You asked the Plan to waive the coinsurance for MRI's. You say that the cost is too expensive, and you need 
something more reasonable. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare-covered radiological diagnostic services, not including x-rays.  
 
 
 
 
 
 You have been asked to pay $750.60 which is 20% of the allowed amount for the MRIs. The allowed amount 
for the MRI of the pelvis is $1,718.70(20% x $1,718.70=$343.74). The MRI for the abdomen is 
$2,034.30(20% x $2,034.30=$406.86). The MRI's 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 coinsurance for the MRIs 
provided on February 9, 2022.