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

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on October 6, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are not paying this bill because 
you did not know you had a copayment. You also say that you never received a benefits book with cost sharing 
information. 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 $50 
copayment for Medicare-covered diagnostic CAT scan at a freestanding provider.  
 
You have been asked to pay a $50 copayment for a CT scan. The CT scan 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 CT scan provided on October 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the degarelix injection provided on March 
16, 2020, and the denosumab and leuprolide acetate injection provided on September 29, 2020. 
 
You asked the Plan to waive the cost sharing for the injections. You say that you do not agree with the cost 
sharing. 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 20% 
coinsurance for Medicarecovered Part B chemotherapy drugs and other Part B drugs. 
 
You have been asked to pay a cost share of $675.38 for the injections ($3337.56 allowed amount for two 
injections x .20 = $667.51 coinsurance amount) ($667.51 coinsurance amount + $7.87 third injection = 
$675.38). You are only being asked to pay $7.87 for the third injection, which is less than the 20% coinsurance 
because you met your out-of-pocket maximum. 
  These items/services fall 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 cost sharing for the degarelix injection provided on March 16, 2020, and the 
denosumab and leuprolide acetate injection provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased from 
the out-of-network (OON) provider on October 27, 2022. 
 
You asked the Plan to issue reimbursement 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 are not payable as 
they were purchased from an out-of-network provider. 
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased from the out-of-network (OON) provider on  
October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on October 28, 
2022. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you should not be charged for 
the lab work because this was part of an annual checkup. 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 a $450 in-network deductible which applies to certain items and 
services. The Plan deductible applies to laboratory services.  
 
The item or service you asked the Plan to waive the deductible for falls within the laboratory benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 deductible which 
applies to labs. This cost sharing is a contractual obligation that had not been met at the time laboratory 
services were received on October 28, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for laboratory services provided on October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric/detoxification services 
provided from May 21, 2022, through June 25, 2022. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the acute inpatient psychiatric/detoxification services provided. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient services provided were not medically necessary. Our physician reviewer found that the enrollee 
was admitted for the acute inpatient psychiatric/detoxification hospitalization on May 21, 2022 with Alcohol 
Use Disorder, Severe with Mild-Moderate Withdrawal. Based upon the review of the records provided, it was 
not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to 
self or others, auditory or visual hallucinations, delusions, and was not showing any behavioral issues. He was 
not showing any withdrawal symptoms as his Clinical Institute Withdrawal Assessment (CIWA) score was 
found to be 2-3. It did not appear medically necessary and reasonable to have psychiatric/detoxification care 
provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness 
to self or others, perceptual disturbance including delusions, and auditory or visual hallucinations. The health 
plans denial of inpatient psychiatric/detoxification services provided appears appropriate. This enrollee did not 
appear to require inpatient mental health/detoxification treatment as he was not a danger to himself or others 
and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear 
that the services were reasonably expected to improve the enrollees condition or were for the purpose of a 
diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon the review 
of the records provided, the enrollee did not meet criteria for coverage of the acute inpatient mental 
health/detoxification treatment provided.  
 
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 pay for the acute inpatient psychiatric/detoxification services provided from May 21, 2022, through 
June 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
18, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copaymet. 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 $390 
copayment for outpatient surgery. 
 
You have been asked to pay a $390 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 outpatient surgery 
provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781) 
provided on September 22, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the deluxe frames and progressive lenses. You say that you were not made aware 
until the end of your appointment that this provider is OON. The Plan denied your request. The Plan says 
routine eyewear is not covered when provided OON. 
 
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 these services when obtained from a provider in the Plan's routine vision vendor's 
network 
 
We looked at the file and the Plan's rules. In this case the provider is not part of the Plans routine vision 
vendors network. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames 
and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
deluxe frames (V2025) and progressive lenses (V2781) provided on September 22, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service March 23, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88341, 88342, 88360, and 88381 billed for date of service March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q0092 and R0070 provided on September 
10, 2022. 
 
You asked the Plan to pay for Q0092 and R0070. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
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 find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, the 
documentation submitted did not include any set up of x-ray equipment; therefore, code Q0092 cannot be 
verified. The documentation does not include documentation of transportation of x-ray equipment; therefore, 
code R0070 cannot be verified.  
 Based on this information, we decided that Medicare rules for coverage of Q0092 and R0070 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes Q0092 and R0070 provided 
on September 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 14, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. 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 services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 office visit provided on September 14, 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. The Plan denied your request. The Plan says will 
continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition 
is stable for transfer to an alternate level of care, such as a skilled nursing facility, or until the clinical 
circumstances change such that LTACH may be reconsidered 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network urgent care visit provided 
on June 23, 2022. 
 
You asked the Plan to waive the copayment for out-of-network urgent care visit. You say that you disagree 
with the copaymet. 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 $65 
copayment for out-of-network urgently needed services. 
 
You have been asked to pay a $65 copayment for out-of-network urgent care visit. This item/service falls 
within the out-of-network urgently needed 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 out-of-network urgent care visit provided on June 23, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) (37215). 
 
You asked the Plan to pre-approve PTA. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the PTA is covered when used under certain 
conditions. 
 
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 PTA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the request is not medically necessary 
because the records show the enrollee does not have greater or equal to 80% carotid artery stenosis. The review 
has determined that the enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous transluminal angioplasty (PTA) (37215).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 07, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copaymet. 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 $385 
copayment for ambulance services. 
 
You have been asked to pay a $385 copayment for ambulance services. This item/service 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 services 
provided on August 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
21, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. 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 $30 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 office visit provided on April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zofran. 
 
You asked the Plan to pre-approve Zofran. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered 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 Zofran.  
 
Benefits for Zofran 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 pre-approve a computed tomography (CT) Scan. 
 
You asked the Plan to pre-approve a CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
experimental/investigational and cannot be recommended at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the CT imaging of the heart without 
contrast material with quantitative evaluation of coronary calcium is considered experimental/investigational 
for the evaluation and management of the enrollee's medical condition. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) Scan.