Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit with a specialist provided on 
May 4, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were advised by the doctors 
office that there would be no charge for a consultation. 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 $45 
copayment per visit for a specialist office visit.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit 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 the office visit with a specialist provided on May 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (code 71046) provided on January 12, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that medical records have been provided to support 
payment. The Plan denied your request. The Plan says the chest x-ray performed on this date of service was not 
medically necessary. There is no diagnosis showing the medical necessity of this test preoperatively. 
 The Plan follows Medicare rules. Medicare rules say that preprocedural chest X-rays in the absence 
of symptomatic pulmonary or cardiac diseases are generally not covered.  In order to be covered, the reason(s) 
for the x-ray must be documented in the clinical chart with an explanation of how the results of the x-ray would 
be used for the patients care. 
 
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 chest x-ray. Our reviewer says that the 
chest x-ray was not medically necessary. Our physician reviewer found the only history available is 
"osteoarthritis".  Performing an x-ray for preoperative purposes only is not a valid reason or symptom for this 
test. 
 
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 chest x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for the chest x-ray (code 71046) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical tooth removal (D7210), a bone replacement graft 
(D7953) and a guided tissue regeneration (D4266), provided by an out-of-network provider on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that this provider is in-network. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a surgical tooth removal (D7210), a bone replacement graft (D7953) and a guided tissue regeneration 
(D4266), provided by an out-of-network provider on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this with was a follow up to a 
surgery and you should not be charged for this. 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 $20 
copayment per visit to an ophthalmologist or optometrist.  
 
You have been asked to pay a $20 copayment for the office visit. The office visit 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 waive the copayment for the office visit provided on June 
11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found review of peer reviewed evidence finds no support for intensive rehabilitation following uncomplicated hip arthroplasty. The rehabilitation is uncomplicated and frequently done at home and 
as outpatient. There is no indication for frequent physiatry oversight. There is no indication for rehabilitation 
nursing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia  first 15 minutes (D9222) 
and deep sedation/general anesthesia  each subsequent 15 minute increment (D9223) provided on February 
14, 2022. 
 
You asked the Plan to pay for the deep sedation/general anesthesia. You say that you were recommended to 
have these services due to your extreme gag reflex, extreme pain, and sensitivity. The Plan denied your request. 
The Plan says the service provided is not a covered benefit under your dental 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 deep 
sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  each subsequent 
15 minute increment (D9223) provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the request for Intracept intraosseous 
basivertebral nerve ablation at L3-4 is not medically reasonable or 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation provided from February 21, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for ophthalmological services: medical examination and 
evaluation. The Plan denied your request. The Plan says the claims processed with the correct copayment. 
 
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 Vision Care, services for the diagnosis and treatment of diseases and injuries of the eye.  
 
You have been asked to pay a $40 copayment for each of the ophthalmological services: medical examination 
and evaluation. The ophthalmological services: medical examination and evaluation falls within the Vision 
Care, services for the diagnosis and treatment of diseases and injuries of the eye 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 ophthalmological services: medical examination and evaluation 
provided from February 21, 2022, to April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic drugs (D9610), deep sedation (D9222, D9223), 
and biologic materials to aid in tissue regeneration (D4265) provided on March 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you assumed these services were covered. The 
Plan denied your request. The Plan says therapeutic drugs (D9610), deep sedation (D9222, D9223), and 
biologic materials to aid in tissue regeneration (D4265) 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 pay for 
therapeutic drugs (D9610), deep sedation (D9222, D9223), and biologic materials to aid in tissue regeneration 
(D4265) provided on March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on March 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 
copayment for Medicare-covered outpatient hospital surgery and other services. We cover medically-necessary 
services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. 
Covered services include but are not limited to services in an emergency department or outpatient clinic, such 
as observation services or outpatient surgery. The provider billed in the amount of $524.85 and the allowed 
amount is $329.64. This is less than the copayment amount. Therefore, results in the total cost sharing amount 
of $329.64. 
 
 
 You have been asked to pay a $329.64 copayment, which is less than the copayment for outpatient surgery. 
Outpatient surgery falls 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 on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 0037U is targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
February 24, 2021, rather than the billed date of service February 16, 2022. There is no documentation to 
support genetic testing on the billed date of service. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the FoundationOne CDx (F1CDx) test (0037U) provided February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told the provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation does show that you have functional impairments however 
there is no documentation to show that you require or would tolerate intense therapy. There is no documentation to show that you require medical monitoring on an inpatient basis as medical comorbidities are 
currently being monitored on an outpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on January 6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not received timely. 
 
The Plan must follow Medicare rules. The rules say that home health claims must be submitted within five 
calendar days from the start of care. 
 
We looked at the file and Medicare rules. The file shows that the claim was not received within five calendar 
days from the start of care. 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 home health 
services rendered on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an immediate denture - upper (D5130) and 
immediate denture - lower (D5140) provided on April 28, 2022. 
 
You asked the Plan to waive the cost for the dentures. You say that this should have been billed under medical, 
not dental, because the dental issues are due to an accident. The Plan denied your request. The Plan says the 
cost share 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 50% of 
the cost for covered services up to the annual benefit maximum.  
 You have been asked to pay $1,499 for the dentures. The dentures fall within the Major Dental 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 cost for an immediate denture - upper (D5130) and immediate 
denture - lower (D5140) provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist telehealth visits provided from 
February 1, 2021, to October 5, 2021. 
 
You asked the Plan to waive the copayments for specialist telehealth visits. You say that the office told you 
there would not be a copayment, therefore you feel you should not have to pay these copayments. The Plan 
denied your request. The Plan says the copayments applied was 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 $35 
copayment for physician/practitioner services, including doctor's office visits. 
 
You have been asked to pay a $840 copayment for specialist telehealth visits (24 visits x $35 = $840). 
Specialist telehealth visits falls within the Physician/Practitioner Services, Including Doctor's Office Visit 
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 copayments for specialist telehealth visits 
provided from February 1, 2021, to October 5, 2021.  
 
Your complaint about the office giving you incorrect information is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0037U) provided February 8, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that genetic testing panels that test for the FANCC gene are non-covered 
per Medicare Local Coverage Article: Billing and Coding: MolDX: FANCC Genetic Testing (A53628). 
 
The Plan must follow Medicare rules. Medicare rules say that effective for services performed on or after 
March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation 
Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when 
performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a 
treating physician, and when coverage rules are met. 
 
We looked at the file and Medicare rules. This service is covered nationally under the National Coverage 
Determination for the enrollee's cancer. A local non-coverage determination can not support a denial for a 
nationally covered service. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have been met. Therefore, we decided that the Plan has to pay for genetic testing (0037U) 
provided February 8, 2022.  
 
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.